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CENTRAL MN YOUTH FOR CHRIST – PARENTAL CONSENT AND RELEASE OF LIABILITY
Period: 6/1/2020 – 7/1/2021

1. RELEASE OF LIABILITY:

I understand that the opportunity to attend CENTRAL MN YOUTH FOR CHRIST activities is a privilege. In consideration for that privilege, I am signing this Release of Liability form on behalf of myself and my minor children. I understand that my child may participate in any number of physical activities some of which include, but are not limited to, recreational and adventure activities and games (Rock climbing, mountain biking, skiing, kayaking, horseback riding, etc.). I understand that there are certain risks of physical injury or illness associated with these activities. In addition, I understand that there may be other risks associated with these activities of which I may not be presently aware. By signing this Release, I expressly assume these risks for myself and/or my child, whether such risks are known or unknown to me at this time and certify that I and/or my child is healthy and fit to participate. I release CENTRAL MN YOUTH FOR CHRIST including its affiliated chapters, affiliates, and their officers, directors, volunteers, employees, contractors and agents, from any claim that I or my children may have now or in the future against them for any accidental physical or other personal injury, loss of personal property, illness or death caused by infectious and/or contagious diseases or sickness while at camp or other YFC activities, or during YFC travel to and from camp or other YFC activities, and any medical responses to the same, as well as any other claims arising from participation in CENTRAL MN YOUTH FOR CHRIST activities. This release of liability shall cover (without limitation) all claims for negligence and breach of fiduciary duty asserted by my child or myself or any person made on their behalf. This Release specifically covers claims caused in whole or in part by any U.S. national health crisis, epidemic, pandemic, or similar widespread outbreak of disease whether or not such is formally declared by the U.S. government, the Center for Disease Control or the World Health Organization. YFC reserves the right to follow recommended CDC guidelines related to such pandemic, outbreak or disease and as such may choose at any time to send a participant home if presenting signs of sickness.

2. AUTHORIZATION FOR MEDICAL TREATMENT

With the increasing sophistication of the medical system, I understand it may be necessary to have a parental consent form present in the unlikely event of an injury or condition requiring medical treatment of my child. This consent and release gives CENTRAL MN YOUTH FOR CHRIST and its personnel the permission to take my child to the nearest, available medical facility and have any necessary emergency treatment administered. IN CASE OF EMERGENCY, I UNDERSTAND THAT EFFORTS WILL BE MADE TO CONTACT ME; HOWEVER IF I CANNOT BE REACHED, I HEREBY GIVE CENTRAL MN YOUTH FOR CHRIST AND ITS REPRESENTATIVES THE PERMISSION TO ACT ON MY BEHALF IN SEEKING EMERGENCY MEDICAL TREATMENT FOR MY CHILD IN THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY OR ADVISABLE FOR MY CHILD'S HEALTH, SAFETY AND WELFARE. I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO, USING THE MEASURES DEEMED NECESSARY. I RELEASE CENTRAL MN YOUTH FOR CHRIST ITS REPRESENTATIVES, AND ALL MEDICAL PROVIDERS FROM LIABILITY IN ACTING IN THIS REGARD AND RENDERING SUCH MEDICAL TREATMENT. I WILL BE FULLY RESPONSIBLE FOR ALL SUCH MEDICAL EXPENSES. I represent that I am the parent/guardian of the child named below, who is under 18 years of age. In consideration for allowing my child/ward to participate in CENTRAL MN YOUTH FOR CHRIST activities, I hereby consent to the foregoing on behalf of my child/ward and agree that this release shall be binding upon me, my child/ward, and our heirs, legal representatives and assigns.

I hereby agree to defend, indemnify and hold CENTRAL MN YOUTH FOR CHRIST including its chapter affiliates, their directors, volunteers, employees, contractors and agents, harmless from any liability asserted by my child/ward subsequent to his or her reaching majority, including reasonable attorney's fees and costs. I also warrant that my child/ward is physically fit and able to participate in all CENTRAL MN YOUTH FOR CHRIST activities.

3. MEDIA RELEASE

See below

4. BEHAVIORAL AGREEMENT

I understand that illegal or immoral activities or behavioral issues may result in the named participant being sent home at the expense of the parent(s)/guardian(s). (These activities would include but not be limited to the possessions and/or use of drugs, alcohol or weapons; sex outside of the marriage relationship; stealing; fighting; threatening or abusive speech, etc.) CENTRAL MN YOUTH FOR CHRIST will make efforts to contact the parent(s)/guardian(s) to make arrangements before the named participant is sent home.

MEDICATION INFORMATION

Any medication brought a program/event must be accompanied by written instructions from a physician/parent. All prescriptions must be brought in the original container in which they were issued (with medical instructions, dosage information, etc.).

Today's Date: December 5, 2020

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contacts

Who to contact in case of an emergency: 


Name

Relationship

Day Phone

Evening Phone

Alternate Contact: 


Name

Relationship

Day Phone

Evening Phone
Additional Information

Physician's Name

Phone

Insurance Co.

Policy Number
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
3. MEDIA RELEASE I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST. YFC also reserves the right to use and reproduce any artwork or other created work (writings, music etc) produced by my child (or me) for the purpose of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST.*
No
Yes

Central MN Youth For Christ Information Form

*Please note: All information must be filled out for your child to participate. The majority of our programming is funded by grants and scholarship dollars. This information is necessary so we can continue to make scholarship money available to our Youth for Christ teens. All information is kept secure and confidential.

Is your household female-headed?*
No
Yes
Do you rent or own your place of residence?*
Rent
Own

Total number of people in your household

What ethnicity are the members of your household and how many:


White #

Black #

Black/African American #

American Indian #

Asian #

Hispanic #

Two or more #

OTHER
Household Income Level*
Health History (check any that apply):
Frequent ear infections
Heart disease/defect
Seizures
Diabetes
Bleeding/clotting disorders
Hypertension
Psychiatric treatment
Asthma
Sleep Walking
Athlete's Foot
Mononucleosis
Chicken Pox
Measles
German Measles
Mumps
Other

If Other

If any items checked, when and how often?

Immunizations

DPT (series of 3)*
No
Yes
Polio Immune*
No
Yes
MMR (Measles,Mumps, Rubella)*
No
Yes

Date of last Tetanus Booster
Allergies (check any that apply):
Hay fever
Insect stings
Penicillin
Aspirin
Food
Other

If Food or Other

Fears/Anxieties

Current Medications (All medications must be in original container.)

Dosage

Other Health History
Please mark all YFC programs that you are involved with.
Band of Brothers-H
Band of Brothers-C
Braid
Wheels
Portable Vision / Audio
Hoop Time
YFC Core
Campus Life
YFC Camp
Full Circle

Verification of Information:

I verify that all the information communicated about my child above is true and current. I do not hold CM YFC or their volunteers or ministry partners responsible for errors in this information. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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