Permission and Medical Release Form

Student’s Name __________________________________ Birth Date ____________________

Address ______________________________________ Phone __________________________

City ____________________________________ State ______________ ZIP ______________

Event ________________________________________ Date(s) of event __________________

We (I), the undersigned parent(s) or legal guardian(s), give permission for participation in the activities of Washington Heights Baptist Church and its youth ministry, New Heights.

Furthermore, we (I) release and discharge Washington Heights Baptist Church, staff and volunteer representatives from any and all liability, claims or demands of any nature whatsoever. We (I) 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, in the event that we (I) cannot be reached in an emergency, we (I) hereby grant permission to said staff or representative to obtain any necessary medical treatment, including but not limited to injections, anesthetic, X-rays, emergency surgery, and hospital care for the participant named above and assume any financial responsibility incurred by the treatment.

We also agree to the Statement of Conduct guidelines listed on the reverse side of this page.

Student Signature ________________________________________ Date ________________

Parent/Guardian Signature _____________________________________ Date _____________

Emergency Phone #’s (Work, Cell, Home etc…) _______________________________________

Doctor’s Name _______________________________ Doctor’s Phone # __________________

Insurance Company _______________________________ Policy # ______________________

Comments or medical problems: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Statement of Conduct

Washington Heights Baptist Church and New Heights youth ministry wish to provide a safe and enjoyable experience for all who participate in youth activities. It is important to understand that Washington Heights represents Jesus Christ in action and attitude. In order to do this, it is critical that the following guidelines be observed:

ü No foul language or violent behavior.

ü No physical contact, public display of affection or sexual activity.

ü Clothing must be modest (no two-piece swimming suits) and free of inappropriate messages or pictures. The youth leaders reserve the right to decide what is acceptable.

ü No disrespectful comments or behavior toward other students or leaders.

ü During an overnight stay, guys and girls will be kept separate and students will not be allowed to leave their assigned rooms after the time designated by the leaders.

ü Guys and girls may not sit together in the BACK ROW of the vans.

ü No smoking, drugs, alcohol, fireworks, firearms, weapons or other illegal items or substances.

While we would regret any inconvenience to you, failure to follow these guidelines will be cause for discipline (loss of privileges, restriction of activities, etc…), and may result in calling parents to come pick up their student immediately at their expense.