Youth Annual Release

Annual Parental Consent and Liability Release Form

(September 2018–September 2019)
Ephrata Community Church, Ephrata, PA

Student’s Name:

Date of Birth:


Parents’ Names:

Primary Contact:

Father’s Cell:

Mother’s Cell:

Parents’ Email:


Health Coverage:

In ‘s name Insurance Provider:

Policy #:

Family Doctor:

Doctor’s #:

Primary Emergency Contact:

Secondary Emergency Contact:

Allergies or Medical Conditions:  

Medicine Being Taken:

We (I) give permission for our (my) child, , to attend and participate in all activities (including any overnight activities) sponsored by Ephrata Community Church.

We understand that in the event medical intervention is needed, every attempt will be made to immediately contact the persons listed in this form. In the event we cannot be reached in an emergency during the activities shown on this form, we hereby give our permission to the physician or dentist selected by the activity leader to hospitalize, to secure x-ray examinations, to secure medical treatment and/or to order an injection, anesthesia, or surgery for our child as deemed necessary.

We understand that our insurance coverage for our child will be primary coverage in the event medical intervention is necessary.

Should it be necessary for our child to return home due to medical reasons, disciplinary action, or otherwise, we assume responsibility for their transportation and/or all transportation costs.

Authorization and permission is hereby given to Ephrata Community Church to furnish any necessary transportation, food, and lodging for our child.

We understand the possibility of unforeseen hazards and know the inherent possibility of risk. We agree not to hold Ephrata Community Church, its leaders, employees, agents and volunteer staff liable for any damages, expenses, or attorney’s fees arising as a result of any negligence, personal injury, death, disease or any other injury or damage incurred or caused by us or our child. 

We understand all reasonable precautions will be taken at all times by Ephrata Community Church and its agents during the events and activities.

We hereby give permission for images of our child and their likeness, with or without name recognition, taken by video, photography, and/or a digital camera, to be copyrighted and/or used solely for the purposes of Ephrata Community Church/Encounter Youth and its partner ministries’ promotional and/or advertising material, website, social media, and publications, whether print and/or electronic, which includes provision to include statements, such as testimonials, quotes, etc. We waive any rights of ownership or compensation thereto. Contact Pastor of Student Ministries Chris Weber at if you have any questions or concerns.

Leave this empty:

Ephrata Community Church
Signature Certificate
Document name: Youth Annual Release
Unique Document ID: 9de5d97e68f5f4bde9048586e1ea185ed427fceb
Timestamp Audit
September 6, 2016 3:27 pm ESTYouth Annual Release Uploaded by Kate Darnold - IP