Rise Liberty Youth Student Release Form

Welcome to Rise Liberty Youth!

If your child is new to Rise or has participated before, please complete the following information so that we have the most up to date information.
We are excited for what God has in store this year and to be able to connect with them on Thursday nights and at Small Groups!

We want to keep your student safe while they are in our care, from the time they get on the Rise bus after school to the time they get home, so please fill out the following form so that we are able to do so!

As always, if you have any questions, please contact our Youth Ministry Leaders at 252-441-6592/ riseyouth@libertyobx.com

Please begin by giving us YOUR basic contact info (first and last name and email) below, then proceed to add YOUR STUDENT(S) information! Please be sure to click "Add Child" for each student that you will be bringing to Rise.

Your name *

Email address *

Student Information

Please provide us with your student's basic information!
Please make sure that you CLICK "ADD CHILD" for EACH student that you are bringing to Rise. Failing to do so will result in the Rise team only having your information and not your student's.

For address please type out full address, only abbreviate state (Example: 244 Williams Drive Kill Devil Hills, NC 27948)

Under medical notes, please list any allergies, medical conditions, or dietary restrictions that your child may have and any medications that your child may take

Household members

Please select "Add Child" for every child you are adding to Rise

Phone number *

Address *

Please list at least TWO other emergency contacts *

Please list first and last name, phone number, and relationship to each contact

Allergies/Dietary Restrictions *

OTC Medications

I, hereby give my consent for my child to receive the following over-the-counter medications.

OTC Headache medicine (Tylenol/Advil)

OTC Allergy medicine (Benadryl)

Immunizations up to date? *

Yes

Physician Name & Phone Number *

Insurance Company & Policy Number *

Medical Release *

As parent or guardian of the minor named above, I do hereby consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services.

I understand that every effort will be made to contact me. If I cannot be reached, I hereby give permission to act on my
behalf in seeking emergency treatment for my child to Rise Liberty Youth Leadership for any necessary treatment.

PARENT/GUARDIAN TYPE NAME BELOW

Liability Release *

In Consideration of Rise Liberty Youth permitting me to participate, I hereby for myself, heirs, administrators, and assigns, waive any and all rights and claims of any nature I may have against Liberty Christian Fellowship and any organization connected with any of the events, their representatives, successors, and assigns for any and all injuries or damages of any nature which I may suffer while taking part in any event. I will assume all risks of any kind that may befall on me or any other person as result of my participation in any event. This waiver and release which includes all claims, demands, costs, losses, damages, attorney’s fees and liabilities shall be binding on my heirs, administrators and assigns and run in favor of Liberty Christian Fellowship. These authorizations shall remain effective unless revoked in writing and delivered to Liberty Christian Fellowship. I HAVE READ THIS WAIVER AND LIABILITY AGREEMENT AND UNDERSTAND THE TERMS USED AND THEIR LEGAL SIGNIFICANCE

PARENT/GUARDIAN TYPE NAME BELOW

Photo/Video Release *

I give permission for my child to be used in photo/video promotions regarding Rise Liberty youth ministry?

Yes

Transportation Consent *

Parental Transportation Authorization:
As the parent/guardian of the above-mentioned child(ren), I give permission for my child to be transported to and/or from Rise Liberty Youth bible studies, youth group or events. All Liberty staff/volunteers are background-checked. I understand that neither Liberty Christian Fellowship nor any of its staff or volunteers are responsible for any injury sustained by my child. I accept responsibility for any medical expenses as a result of any such injury sustained to my child. All of the Rise Youth Leaders driving Liberty Vehicles have been background checked and a DMV report has been run on our transportation team members and are covered under the church's vehicle insurance, Church Mutual.

I understand that my child will be expected to follow the rules set by the youth leadership. Parents will be contacted and expected to pick up their child if their behavior does not comply.

PARENT/GUARDIAN TYPE NAME BELOW

Please list any authorized adults that are able to drop off/pick up your student. (List first and last name and relation) *

In the event you are unable to pick them up, the following adults will have permission to do so.

Please type your name below as an electronic signature for our above consent form *

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