BLUE Permission Form Believers Living United Everyday – a ministry of Mosaic Rockford1300 17th Street • Rockford, IL 61104 • (815)721-6988contact@mosaicrockford.com • mosaicrockford.com/blueYOUTH PARTICIPATION CONSENT FORMName of Youth* First Last Birthdate*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904190319021901daymonthyearGender*malefemaleAddress* Street AddressStreet Address Line 2CityStateZip CodeYouth's Phone Number Area Code - Phone Number Texts ok?yesnoYouth's emailPrimary Contact* First Last Primary Contact Relationship*Primary Contact Phone* Area Code - Phone Number Primary Contact - Texts ok?yesnoPrimary Contact EmailSecondary Contact First Last Secondary Contact RelationshipSecondary Contact Phone Area Code - Phone Number Secondary Contact - Texts ok?yesnoSecondary Contact EmailEmergency Contact* First Last Emergency Contact Relationship*Emergency Contact Phone Area Code - Phone Number Emergency Contact - Texts ok?yesnoEmergency Contact EmailHealth Insurance ProviderPolicy #Phone # Area Code - Phone Number Please list any allergies or medical conditions that may limit participation in any youth activitiesAs necessary, I approve the following medicine(s) to be administered to my child by the designated responsible leader. (Please check all that apply).*Acetaminophen (Tylenol)IbuprofenAspirinCough Drops/MedicineTumsNyquil/DayquilOther (list below)NONE OF THE ABOVEOther medication(s) I accept responsibility for providing BLUE with any prescription medications that my child may need while they participate in any BLUE functions. I understand that I must hand such medications directly to a BLUE leader along with detailed instructions as to when and how the medication is to be administered. The parent/guardian of the youth listed on this form hereby gives consent for their child to participate in BLUE activities, events, outings, programs, and services. Both the parent and child understand that all youth members are expected to follow the directions of the youth leader(s). The BLUE youth leaders assume responsibility for leading at the activity and, if necessary, may require a youth group member to leave the activity due to inappropriate conduct or disobedience. In such an instance, the parent/guardian will assume responsibility for, and costs of, returning the youth group member home. As the legal parent/guardian of the youth listed above, I agree to hold blameless Mosaic Rockford, it’s employees, and any agents, from any and every claim arising, or which may be asserted by me or any member of my family by reason of participating in any activities associated with Mosaic Rockford and BLUE. Further, I do authorize the minister or sponsor of this activity, in the event that I cannot be contacted by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while participating in the activity. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment.As legal guardian of this minor, I *DODO NOTgrant permission for Mosaic Rockford Church (and BLUE) to publish photos of my child in their various forms of publications or on the church’s websites. I give Mosaic Rockford Church the perpetual, royalty-free right to use my child’s photo(s) in any manner including but not limited to publications and the website. (Publication of these photos does NOT include first or last names.) I understand that if I give written notice to the webmaster that I object to any particular picture on the website, it will be removed as soon as possible.By signing below, I understand that I have read and agree to the information given in this entire form. I also acknowledge that I am a legal guardian of the youth listed on the front of this consent.Electronic Signature*Today's Date*01020304050607080910111213141516171819202122232425262728293031 / JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember / 2025202420232022202120202019201820172016201520142013201220112010200920082007daymonthyearThis consent is good for one year from the date signed, but can be renewed annually during the month of June, as long as information has not changed. Consent is considered renewed and valid from June 1 of the current year to June 30 of the following year. Contact us if you have questions.Word Verification:Remember to hit SUBMIT below before you leave this page or your entire form will be deleted.SubmitReset