OBC Youth Registration, Release, And Medical Form

Youth Name*

First NameLast Name

Date of Birth*

MonthDayYear

Youth #2 Name*

First NameLast Name

Date of Birth*

MonthDayYear

Youth #3 Name*

First NameLast Name

Date of Birth*

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parental/Guardian Permission

The undersigned is the lawful parent or guardian of the above child, and consents to the participation by the child in Youth Group activities conducted by Occoquan Bible Church ("OBC") and to the participation of the child in all events.

Medical Consent

The undersigned authorizes any of the OBC employees, representatives, agents (including OBC youth leaders)(collectively "OBC Representatives") to provide for, approve and authorize any health care at any hospital, emergency room, doctor's office or other health care facility; employ any physicians, dentists, nurses, or persons whose services may be needed to provide or facilitate the provision of health care; access, review and if necessary disclose the contents of any medical records; and execute any consent form required by medical, dental, or health care providers relevant to the provision of medical, surgical or dental care of the child. Health care shall include the administration of examinations, X-rays, diagnosis, anesthesia, operations, and other health care procedures.

If time and technology allows (e.g., access to cell phone and cell phone signals), OBC Representatives will first attempt to contact a parent or guardian of the child before administering or authorizing any treatment.

Notwithstanding other provisions in this Permission Form, OBC Representatives shall not have the authority to withhold or withdraw life-sustaining procedures for the child.

Liability Release

The undersigned assumes all risk of injury or harm to the child associated with the participation in OBC Youth Group activities and agrees to release, indemnify, defend, and forever discharge OBC and OBC Representatives of and from all liability, claims, demands, costs, expenses, actions, and causes of action in respect to death, injury, loss or damage to the child or by the child whosoever caused, arising or to arise by reason of or during the child's participation in OBC Youth Group activities.

This permission form may be revoked at any time with written notice to OBC.

Signed on

Date

Parent/Guardian*

First NameLast Name

Signature of Parent/Guardian*

Use mouse to sign

Youth Registration

Youth Information

Parent/Guardian Info

Parental/ Guardian Permission Form and Medical Consent & Liability Release

Medical Information