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BLUE Permission Form

Believers Living United Everyday – a ministry of Mosaic Rockford

1300 17th Street • Rockford, IL 61104 • (815)721-6988

contact@mosaicrockford.com • mosaicrockford.com/blue

YOUTH PARTICIPATION CONSENT FORM

Name of Youth*
Birthdate*
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 / 
Gender*
Address*
Youth's Phone Number
-
Texts ok?
Youth's email
Primary Contact*
Primary Contact Relationship*
Primary Contact Phone*
-
Primary Contact - Texts ok?
Primary Contact Email
Secondary Contact
Secondary Contact Relationship
Secondary Contact Phone
-
Secondary Contact - Texts ok?
Secondary Contact Email
Emergency Contact*
Emergency Contact Relationship*
Emergency Contact Phone
-
Emergency Contact - Texts ok?
Emergency Contact Email
Health Insurance Provider
Policy #
Phone #
-
Please list any allergies or medical conditions that may limit participation in any youth activities
As necessary, I approve the following medicine(s) to be administered to my child by the designated responsible leader. (Please check all that apply).*
Other 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 *

grant 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*
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 / 

This 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:

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