Parental consent form [vc_row][vc_column] A completed form only needs to be submitted one time per year unless health or insurance info changes. You are responsible for notifying us if changes occur. NOTE: If you are 18+ and are completing this form yourself, you will need your health insurance information to submit this form. PLEASE CHECK ONE* I am 18+ and am completing this form for myself I am a parent/legal guardian of a youth under 18 Participant Name* Participant Adress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant or Parent Primary Email* Participant or Parent Primary Phone*Alternate Phone ContactEmergency Contact Name & Phone Number*I give permission for my child to photographed or videotaped for use on TNFellowhsip.com and/or Fellowship Church social media pages'* Yes No MEDICAL INFORMATION: Registrant name*Health Insurance Provider* Group Policy # Family Physician* Physician Phone Number*Allergies (food, nature, medicinal)*List of medications needed during event. Describe: Name of medicine/Dosage/Delivery method/Reason for takingMedications will be kept in a secure location under the guidance of church youth ministry leadership. If the participant is not part of a group, event director will administrate.* I have read / agree I give permission for my child to be given Tylenol, laxative, or other minor medication as needed* Yes No Describe any behavioral or emotional problems that may effect participants stay during eventI understand that all reasonable safety precautions will be taken at all times by the Crossroad Youth Event Staff. I have completed the information to the best of my knowledge. In giving my child permission to attend this event indicated, I release Fellowship United Methodist Church, leaders and event staff from liability for damages, losses, illness, or injuries incurred by my child. I understand that I, or the emergency contact listed on the registration form will be contacted. I hereby give permission to the physician or facility present to order X-rays, routine tests, and treatment for the health of my child.* I agree By submitting my FULL NAME in the field below, I recognize that this is my official electronic signature therefore binding me to the contents of this form. NOTE: There is an option on this page to print and complete a hard copy if preferred.* Δ [/vc_column][/vc_row]