Youth Medical & Media Release 2025-26

A parent or legal guardian must complete this form for each minor (under age 18) student. Please check each section to confirm compliance before submitting.

Your name *

Email address *

Phone number

Youth Participant Information

Student's Name *

Grade *

Birthdate *

Student's Cell

Student's Email

Emergency Information

Emergency Contact Name *

Please list an emergency contact - for minors this is IN ADDITION TO the parent/guardian listed above.

Relationship to Student *

Emergency Contact Phone Number *

Insurance Number

Provider

Name of Policy Holder

Doctor's Name

Doctor's Phone

Health Concerns/Medications/Allergies *

Please list any medical information we should be aware of. In none, please type "None".

MEDIA RELEASE

Media *

Does First Brethren Church of North Manchester have permission to use your child’s still or video image on our website, social media sites, and for media releases (web & print) in which to advertise a church event?

AMATEUR WAIVER AND RELEASE OF LIABILITY

As the parent/guardian of the aforementioned minor (hereinafter referred to as “Minor”), I hereby acknowledge that the Minor is presently under my care and custody. I give permission for the Minor to go to and participate in activities with North Manchester First Brethren Church of North Manchester, Indiana (hereinafter referred to as “church”), including those activities that require transportation to other locations by a responsible adult leader.
THE MINOR IS VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES, INCLUDING TRANSPORTATION TO AND FROM SUCH ACTIVITIES, WITH MY FULL KNOWLEDGE OF THE DANGERS INVOLVED AND HEREBY WE AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY OF SUCH PARTICIPATION AND TRANSPORTATION.
In the event that an emergency arises, I consent to and give my permission to the Church and its staff for the
transportation of participants for necessary health care, for a licensed physician or dentist to provide necessary medical treatment, and for the release of information needed for necessary care. I release and agree to hold the Church and its representatives, or trip leaders harmless and not responsible for any and all claims, actions, damages, and/or liabilities arising out of any accident or sickness, or treatment thereof, incurred by the Minor during activities with the Church.

Timeframe *

I agree that this signed release is effective for the one-year period beginning on August 1, 2025 and ending on August 31, 2026 unless I provide WRITTEN DOCUMENTATION to First Brethren Church of North Manchester stating otherwise.

Agreement l PARENT/GUARDIAN MUST SIGN FOR MINORS *

By applying my electronic signature to this agreement, I agree that my electronic signature is the legally binding equivalent of my handwritten signature on paper. I will not, at any future time, claim that my electronic signature is not legally binding or enforceable. By electronically signing and submitting this agreement, I 1) acknowledge that I have read and fully understand the terms of the agreement; 2) voluntarily agree to be bound by this agreement; and 3) certify that I am 18 years of age or older. My signature applies to all pages of this contract. I understand that if I wish to sign a hard copy of this agreement instead of an electronic version, I must contact the party that requires my signature on this agreement directly.

A parent or legal guardian must sign this agreement on behalf of any minor participant under the age of 18. By electronically signing this agreement, I represent that I have the authority to sign and enter into this agreement on behalf of the minor(s) listed above.

Electronic Signature *

PRINT YOUR NAME BELOW to sign release.

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