IBC Youth Permission / Medical Form

This form applies to all IBC Sponsored Youth programs, events, and activities from
August 18, 2024 to August 17, 2025.

Please complete this form for up to 4 students.

Parent First Name

Parent Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Student Name(s)

Date of Birth(s)

If parents/guardians cannot be reached in case of an emergency, please notify: include name & phone number

Insurance Information

Do you have health insurance?

Yes

No

Name of Insurance Provider:

Policy Number:

Provider Phone Number:

Group Number:

Claims Address:

Medical Information

Family Doctor Name:

Family Doctor: City and Phone Number

Please list for each student: Allergies, Other medical conditions

Please list names and dosages of any medication that must be taken during an extended event. Please list for each student.

Photo Release

Immanuel Bible Church may use photographs of the above named child(ren) for publicity, including Web content (names will not be publicized).

Yes, I agree

No, I do not agree

Statement of Release

Every student ministry activity sponsored by Immanuel Bible Church is carefully planned and supervised by mature adults. However, even with the best of planning and precaution, unforeseen accidents/injuries can occur. By signing this form, the parent or guardian agrees that his/her child(ren) has permission to participate in student ministry activities, and the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related activities/transportation. He or she agrees not to hold Immanuel Bible Church or its employees or volunteers liable for: damages, losses, or injuries to the child(ren) named above. He or she also understands that the signature below is for both a medical and liability release. "In the event that I cannot be reached in an emergency situation requiring medical treatment, I hereby give my permission to the physician or dentist selected by Immanuel Bible Church staff and/or volunteers to administer any and all necessary medical treatment to the above named child(ren), until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, hospitalization, the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. I also agree to accept full financial responsibility for the cost of such treatment.

Yes, I agree

No, I do not agree

Date Input

Signature