Eastside Christian Church - OR - Youth Consent Form

Student Information

Student's First and Last Name

Student's Birthday

Students Email (Optional)

Student Phone Number (Optional)

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Allergies

Parent Information

First Name

Last Name

Parent Email

Parent Phone Number

Emergency Contact Information

Emergeny Contact First and Last Name

Emergency Contact Number

Relationship to Student

Youth Activity Consent

Signature for Consent

List of Activities I DO NOT give permission for.

Questions or Concerns: Contact hunter@eccfamily.com or 406-217-8010

Youth Photo Release Statement

I hereby authorize Eastside Christian Church to publish photographs taken of myself and the minor student listed above, for use in Eastside Christian Church's printed publications, facebook page, fecebook groups, and website. I release Eastside Christian Church from any expectation of confidentiality for myself and any of the undersigned minor children and attest that I am the parent or legal guardian of the student listed above and that I have the authority to authorize Eastside Christian
Church to use their photographs. I release Eastside Christian Church and it's employees from liability for any claims by me or any third party in connection with my participation or the participation of any of the undersigned minor children.

Do you agree to the above Photo Release Statement and consent to your Student's picture possibly being used in Eastside printed material, Facebook pages and groups, and church website?

YES

NO

Youth Authorization for Medical Treatment

Signature

Date Signed

Additional Information: This information will help us get needed care to your student in the case of emergency.

Please list any important medical information not already disclosed.