University Covenant Church Youth
Parental Consent/Medical Release Form


Name of Event:_____________________________________

Date(s) and times of Event:_____________________________




Child's Name:__________________________   Phone Number:__________________   Age:___

Address:_______________________________   City:__________________   Zip:___________

Insurance Company and Policy Number (Required):____________________________________


I, the undersigned, parent or guardian of the child listed above, agree and consent
to have the staff members and counselors of the youth program at University 
Covenant Church, and any other person in the program approved as a parent to secure
any medical care or treatment deemed necessary for my child by a qualified medical
examiner during this event.  I further assume all responsibility for the decision
so made, and the emergency care or treatment so secured by my child.  As well, I
release from all responsibility or liability for accident, and or injury, any and
all representatives, counselors, leaders, or drivers working with the University
Covenant Church youth program.


Signed:________________________   Date:_______   Relationship to Student:__________


Emergency Numbers to Call:

Home:_____________________   Work:____________________   Other:____________________


Please list any medical allergies, medication being taken, medical problems, or any
other pertinent medical information regarding your child:
___________________________________________________________________________________

___________________________________________________________________________________