Youth Health Waiver Form

Student Name *
Student Name
Date of Birth *
Date of Birth
Parent/Guardian *
Parent/Guardian
Parent/Guardian
Parent/Guardian
Emergency Phone *
Emergency Phone
Emergency Phone 2 *
Emergency Phone 2
Name of Policy Holder *
Name of Policy Holder
As participant/parent/guardian of the above named minor(s), I hereby grant permission for my son/daughter to participate in Second Reformed Church Youth Ministry and related events. I also grant permission for Second Reformed Church staff and volunteers to take whatever steps may be necessary to obtain emergency care as warranted for the well being of my son/daughter. My signature below indicates that I understand and agree to the policy and terms listed above and agree that any expenses incurred in necessary emergency or other medical treatment will be borne solely by the student's medical coverage and/or family. I will not hold any leader or organization liable for any injury or accident.
Digital Signature *
Digital Signature
Digital Signature *
Digital Signature