Loading...

First Presbyterian Church

Medical Release Form - Youth

2025-2026

Youth Ministry Covenant

FOR ALL PARTICIPATING Youth AND ADULTS

While participating in any First Presbyterian Youth event, trip, or gathering on or off-campus, I will do my best to live together with others as a family in Christian community. I will love, respect, trust, support, and encourage others. I will seek to create and maintain a safe atmosphere that promotes inclusivity and the image of God in all people.

1. When away from First Presbyterian Church I will recognize that I am a guest to our hosts. And, as a guest, I will be considerate to our hosts and to their leadership team. I will respond to them with gratitude for their hospitality.

2. I agree to abide by all rules laid out by the First Presbyterian Youth Staff and Leaders, and I will be respectful of the Youth Staff and all Youth Leaders.

3. As a member of First Presbyterian Youth, I will:

o Be responsible for my own belongings and respect the property of others

o Participate, as I am able, in all activities of the youth ministry trips and events

o Be respectful of all adult leaders

o Care for and be respectful of the property of First Presbyterian Church, and/or, our hosts

o Be appropriate in my expressions of care and concern

o Not bring or use any harmful substances or weapons including, but not limited to: weapons of any kind, fireworks, drugs, alcohol, or tobacco products

o Treat all people I encounter with love and respect

4. As a participant in the Youth Ministry of First Presbyterian Church, I agree to abide by this covenant while participating in any First Presbyterian Youth trip, event, or gathering on or off-campus. I understand that breaking this covenant may result in my parents being notified, and that I may be asked to go home at my parent's expense.

Please refer all questions to: 

Rev. Andrew Esqueda

aesqueda@firstpreswc.com

Please select who will be participating...
Minor
Continue
First Participant's Name
First Name*
Middle Name
Last Name*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Contact and School Information
Name Youth Goes By: *
Youth Phone #
I give permission for my youth to be added to the Middle School or High School Group text (If applicable) *
Yes
No
Youth Email
School *
Grade *
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:*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Insurance
Insurance Carrier*
Insurance Policy Number*
Insurance Carrier Phone Number *
Name of Policy Holder *
Medical History
Year of Last Tetanus Shot *
Priimary Doctor *
Doctor Phone Number *
Allergies and Medical Conditions
Known Allergies (especially to foods & medications) *
Regular Medication - Description and Schedule: *
Medication Administration (Check if applicable):
I want you to remind my child to take his/her medication
I want First Presbyterian youth staff to keep and administer my child's medication
Parent or Guardian's Email Address
Email*
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.

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.

Permission and Release

My child/dependent, named above in the "Minor/Participant Information" section, has my permission to travel to and from and to participate in First Presbyterian Church trips and activities under First Presbyterian supervision from 01/01/2025 to 12/31/2026.

In consideration for the privilege of participation in any and all trips or activities, I agree to release and hold harmless First Presbyterian Church, its employees, pastors, directors, volunteers, and agents, from any liability without limitation, including those predicated upon negligence for bodily injuries, including those resulting in death, illnesses, damages to myself, and including the contraction of viruses or infections whether the virus or infection occurs before, during, or after participation in any and all First Presbyterian Youth events.

If I cannot be contacted in the event of injury, illness or medical emergency, I hereby authorize First Presbyterian Church to seek medical, rescue, or evacuation services for the above-named child/dependent with the understanding that I am responsible for any expenses incurred.

I also understand that I am required to provide First Presbyterian Church with updated medical information on my child/dependent should any of his/her medical information change between the date I sign this form and 12/31/2026.

I hereby also grant First Presbyterian Church the right to photograph and film my child/dependent during any First Presbyterian activities, with the understanding that his/her pictures or videos may be used in promotional materials or otherwise published in print, digital or web form.

By signing this document, I confirm that I have authority to sign, have read the entire document, and understand that the document waives certain rights of the person signing and the participant.



By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
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 Date of Birth*
Date of Birth
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!