Grace Student Ministries 2025-2026 Parental Consent Form

This form gives permission for the listed student to participate in activities sponsored by Grace Family Church from September 1st, 2025, to August 31st, 2026.

Your name *

Email address *

STUDENT INFORMATION:

Student's Full Name: *

Birthday *

Grade *

Address *

Does this student have a cellphone?

PARENT/GUARDIAN INFORMATION:

Name of Parent or Guardian: *

Is your address the same as your student's?

Phone number *

Email Address: *

What is your relationship to the student? *

EMERGENCY CONTACT INFORMATION:

Name of emergency contact person if Parent/Guardian cannot be reached: *

Phone Number of Emergency Contact Person: *

What is the Emergency Contact Person's relationship to the student? *

STUDENT'S MEDICAL INFORMATION:

Is your teen allergic to any types of medication? *

Is your teen allergic to any food? *

Is your teen allergic to bee stings or any insect bites? *

Is your teen allergic to any environmental substance or object? *

Does your teen use an inhaler? *

Can your teen swim? *

Does your teen have any physical impairments or medical conditions which would prevent him/her from participating in normal rigorous activity? *

Which over-the-counter medication can your teen have? (select all that apply) *

Here is a list of over-the-counter medications that Grace Student Ministry (GSM) leaders may have available to give to your child, as needed, at youth group, church, or any other Grace Family Church event/function. Please check the box for any medication your teen is allowed to receive. If your child can receive the medication, we will follow the directed dosage listed on the medication, unless otherwise instructed by you in the following question. If you would like your child to NOT receive any over-the-counter medication, then please select the last option.

Tylenol

Ibuprofen (Advil)

Aspirin

Pepto Bismal

Benadryl

Immodium

Cough Drops

Eye Drops

MY STUDENT IS NOT ALLOWED TO HAVE OVER THE COUNTER MEDICATION

Do you have any specific directions, or dosage amounts for any of the listed over-the-counter medications in the previous question?

If there is any other information about this student that you believe would be beneficial for Grace Student Ministry leaders here is the place to let us know.

Consent and Certification:

I, the undersigned, being the parent or legal guardian of the teen named above do hereby consent to the participation of my teen in all of the regularly scheduled activities of the youth group of Grace Family Church of New Holland, Pennsylvania, including retreats, conferences, campouts, swimming, boating, hiking, sporting events, and any other activities customarily associated with a church youth group. Further, I certify that my child is physically fit and adequately trained to participate in such events unless otherwise noted.

Medical Treatment Authorization:

I understand that I will be notified in the case of medical emergency involving my teen. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my teen becomes injured or ill. I understand that Grace Family Church of New Holland, Pennsylvania WILL NOT be responsible for medical expenses incurred, but that such expenses will be my responsibility as the parent or guardian. I agree to notify Grace Family Church of New Holland, Pennsylvania in the event of any health changes, which would restrict my teen’s participation in any normal youth activities. I also understand that the adult staff members reserve the right to restrict my teen from any activity that they do not feel is within the physical capabilities of my teen.

Consent to Photo Use:

I, the undersigned, being the parent or legal guardian of the teen named above do hereby consent that my child’s name and image may be stored by and used in Grace Family Church of New Holland, Pennsylvania, publications both printed, electronic, and on any website created by or for the benefit of Grace Family Church of New Holland, Pennsylvania. I understand that I will most likely not be contacted for individual uses of particular images or videos.

Consent to Transport:

I, the undersigned, being the parent or legal guardian of the teen named above do hereby consent that my child may be transported by staff or volunteers of Grace Family Church of New Holland, Pennsylvania in personal vehicles and rented buses and vans.

Disciplinary Agreement:

I, the undersigned, being the parent or legal guardian of the teen named above understand that while the named teen participates in any activity, trip, function, or the like either sponsored by or participated in by Grace Family Church of New Holland, Pennsylvania, is responsible to abide by the rules set forth by the sponsored organization, its leaders and/or all supervisory personnel. Any infraction of rules and/or conduct by the above-named person(s), deemed to be serious by any director or properly appointed staff member of Grace Family Church of New Holland, Pennsylvania, can result in corrective action, up to and including dismissal from the event. In the event that the named teen is dismissed from the program, the teen's parent or legal guardian agrees to assume the entire cost of returning home. I fully understand and agree that there will be no refund of the cost of returning home.

Signature of Parent or Guardian (Please Type Full Name Below): *

Date Signed: *

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