Consent Release Form For Young Life Activity


For area use only: Area # _____________ 
I or my child will be participating in a Young Life activity: _______________________________________________
Enter description and date of activity here
NOTE TO PARTICIPANT/PARENTS-GUARDIANS: Young Life wants you or your child’s experience to be a safe and
healthy one. However, in the event of an accident or illness, it is important that we have the following information:
Name of Participant___________________________________________ Birth date _______________ Age____ Sex___
Last, First, Middle
School/Grade_____________________________________ Participant’s Phone Number _________________________
Parent/Guardian/Spouse/Emergency Contact Information
Name of Parent/Gaurdian/Spouse______________________________________Relationship_____________________
Last, First, Middle
Phone Number_________________________________ Email Address_______________________________________
Home Address____________________________________________________________________________________
Emergency Contact (
) _____________________________________________________________
Different from above
Name / Relationship / Phone Number
Any allergies or other medical needs? _______________________________________________________________
Limits to activities________________________________________________________________________________
Name of Physician_________________________________________________Physician Phone________________
Medical Insurance Company__________________________________________Policy Number_________________
I will not hold or attempt to hold Young Life liable for any loss, damage, or injury to person or property caused by any act or neglect of other persons, or
caused in any manner other than the willful or negligent act of Young Life, its agents and employees, and will indemnify and hold Young Life harmless
from any liability for damages or claims against Young Life arising out of or in any way related to any such loss, damage or injury.
I release Young Life, including its trustees, employees and agents, from me or my child’s physical injury, including death, or illness while at the activity.
I/We will assume the risk associated therewith, whether known or unknown to me/us at this time. This release is also intended to include all claims of my
family, estate, heirs, personal representatives or assigns.
Authorization for Treatment:
I/We hereby give permission to the medical personnel selected by Young Life to secure and administer treatment and to maintain and/or release any
medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation
for the above named person. To obtain a copy of Young Life’s Notice of Privacy Practices, log on to or call (719) 381-1950.
I verify that I or child named above is in good health and capable of participating in strenuous activities and, when necessary, will tailor my/their activities
to those within the bounds of my/their physical health.
I recognize that any medical treatment that is provided to me (or my child) while attending a Young Life activity will be paid for by my medical insurance
company and guarantee payment for services not paid by insurance. Young Life provides SECONDARY insurance for accidents in the amount of
$20,000 medical, $4,000 dental. Claims less than $250 are covered in full by Young Life.
I hereby grant Young Life permission to use, reproduce, and/or distribute photographs, films, video and sound recordings of me or my child without
compensation or approval, for use in materials created for purposes of promoting the activities of Young Life, including the
Signature__________________________________________________________________ Date_____________________________
YL‐1716 (Dec 2016) 


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Parent category: Medical