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Cheyenne Berean Youth Event Permission Slip

Student Name: _______________________________________________________________

Address:______________________________________________________________________

Emergency Contact:___________________________________________________________

Home Phone:_________________ Work:___________________ Cell:__________________

Church Policy:  Due to our Insurance carrier requirements, prudence, and good stewardship of God’s provision, we require the following:

1. All Junior and Senior High youth students participating in any church sponsored event will have this signed permission form returned to the church leader responsible for the event. 

2. All drivers for the event will have a current Drivers Approval Request form on file at the office.

3. All drivers will 21 years of age or older.

4. Any exceptions to the policies will be handled and approved before the day of the event.  Once the event has started, there will be no deviation from the policies unless an emergency situation arises.

5. Persons participating in a church sponsored event may not drive any other vehicle to, during, or from the event without special permission from their parent and or guardian.  If permission is granted, only family members (no friends) may ride in the same vehicle. 

6. The church leader responsible for directing the event has the last word on all matters of direction and discipline.  If it becomes necessary for a person to be brought home early, that person forfeits participation in the next event and mandates parental contact.   

Medical:  I (we) give my (our) permission to the church leader to secure the services of a licensed doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or other medical treatments including anesthesia, for my child’s well-being.  I (we) assume the responsibility for medical bills, if any.

Insurance Company:______________________________   Policy/Group No.:________________

Physician:___________________________  Physician’s Phone No.:________________________

Please list any medical allergies , medications being taken, medical problems, or other pertinent information on the back of this form. 

Liability:  I (we) do hereby release, forever discharge and agree to hold harmless the Cheyenne Berean Church, its leaders and its youth staff from any and all liabilities, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child participant that occur while said child is participating in the above described trip or activity.  Further, authorization and permission is hereby given to the Cheyenne Berean Church to furnish any necessary transportation, food and lodging for this participant.  The undersigned further hereby agrees to hold harmless and indemnify the Cheyenne Berean Church as the result of negligent, willful or intentional acts of said participant, including expenses occurs attendant thereto.  

Parent Signature:_______________________________   Date signed:____________________