C3 Youth Parental Consent Form 2025-2026

June 1, 2025-May 31, 2026

Your name *

Last name

Email address *

Youth Information:

Name *

Email:

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone number

Phone type

Gender *

Birthday *

Grade: *

For 2025-26 School Year

Parent/Guardian Names *

Parent/Guardian Best Contact Phone: *

Parent/Guardian Email *

To Whom It May Concern:

The undersigned does hereby give permission for our (my) child, listed above, to attend and participate in all activities & all trips sponsored by Centralia Community Church of God, Centralia, WA for the period of __6__/_1__/_2025__–__5__/_31_/_2026__

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization. We (I) do hereby release, forever discharge and agree to hold harmless the Centralia Community Church of God in Centralia, WA and the directors thereof from any and all liability, 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-participant is participating in the above described trip or activity.

Furthermore, we (I) (and on behalf of our (my) child-participant), hereby assume all risk of personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein.

Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food, and lodging for this participant.

The undersigned further hereby agree(s) to hold harmless and indemnify said church, its directors, employees, and agents, for any liability sustained by said church as the result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto.

Hospital Insurance? *

Insurance Company and Policy Number

Emergency Phone Numbers *

Physician: *

Physician's Phone: *

Is your child having any of the problems listed below?

Check all that apply. Please explain any problem areas identified below in the "remarks" section.

Hay fever, asthma, or wheezing

Eczema or frequent skin rashes

Convulsions/seizures

Heart trouble

Diabetes

Frequent colds, sore throat, or earache

Trouble passing urine or bowel movement

Shortness of breath

Menstrual problems

Other

History of emotional/behavorial disturbance? *