South Park Church Children’s/Student Ministry
Devar Emet Messianic Synagogue & Outreach [pic][pic]
Parental & Medical Release Form: School Year 2016-2017
7800 Niles Skokie, IL 60077 / (847) 674-9146 / info@ /
One form may be done for the entire family as long as the following apply:
1. Parent/Guardian(s) and Minors all have the same address
2. All Minors have the same insurance carrier/information
To Whom It May Concern:
The signer of this document gives permission for their child(ren) to attend and participate in activities sponsored by Devar Emet Messianic Synagogue & Outreach during the 5777 Jewish calendar year (September 2016 – August 2017). (S)he hereby grants permission for their child(ren) to participate in Devar Emet’s Club Maccabee and/or HaDerekh Youth activities and agrees to hold harmless Devar Emet Messianic Synagogue & Outreach and its respective leaders, officers, directors, employees, and event volunteers from and against liability, damages, or obligations.
For activities that will require leaders to drive to outside locations, the signer of this document gives permission for their child(ren) to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Club Maccabee and/or HaDerekh Youth; after activities are completed, the child(ren) will be returned to Devar Emet Messianic Synagogue to await pick-up from the signer/other guardians or to their homes, if such arrangements have been made prior to the event with youth leaders and the signer/other guardians. Additionally, please note that select pictures & video of activities may be used by Devar Emet Messianic Jewish Outreach & Devar Emet Messianic Synagogue for promotional purposes.
Child #1: Name ____ __________________ Birthday: ___________ Grade/Age ________
Programs your child will attend (circle all that apply):
Teen Night Out HaDerekh Youth Events HaDerekh Youth Overnight Activities
Boys & Girls’ Night Out Club Maccabee Teen Midweek Studies
Address __________________________________ Phone___________________
City ______________________________ Zip __________ Grade _______________
Additional Siblings:
Child #2 Name: __________________________ Birthday: ____________ Grade/Age: ________
Programs your child will attend (circle all that apply):
Teen Night Out HaDerekh Youth Events HaDerekh Youth Overnight Activities
Boys & Girls’ Night Out Club Maccabee Teen Midweek Studies
Child #3 Name: __________________________ Birthday: ____________ Grade/Age: ________
Programs your child will attend (circle all that apply):
Teen Night Out HaDerekh Youth Events HaDerekh Youth Overnight Activities
Boys & Girls’ Night Out Club Maccabee Teen Midweek Studies
As the parent or guardian, I do also authorize the treatment by a qualified and licensed medical doctor of the following minor(s) in the event of a medical emergency which (in the opinion of the attending physician) may endanger life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. I also release Devar Emet Messianic Synagogue & Outreach as well as other organizations, congregations and individuals involved with Club Maccabee and/or HaDerekh Youth, of any liability or costs for accidents incurred during any of the Club Maccabee and/or HaDerekh Youth activities.
Family Physician: _____________________________ Phone: ____________________
Address: _____________________________________________________________
Hospital Insurance: Yes No
Insurance Company: _______________________ Policy Number: __________________________
Food Allergies to be aware of: ________________________________________________________
Medication your child needs: _________________________________________________________
Medication we are allowed to administer to your child(ren): ________________________________
Is there anything else we should know to better accommodate your child(ren) at our events?
____________________________________________________________________________________
I have read and am in agreement with the stipulations of this form. I have signed it of my own free will for the purpose of registering my child for the Club Maccabee and/or HaDerekh Youth 2016-17 Activities, a Messianic Jewish youth group that teaches that Yeshua (Jesus) is the Promised Jewish Messiah, and authorizing medical treatment under emergency circumstances in my absence.
Signed_________________________ Print Name ____________________ Date_______________
Relationship ______________________________ (i.e. Father, Mother, Legal Guardian)
Best Phone # to call in case of emergency: _____________________________
Other contact in case of emergency:
Name_______________________________ Relationship ____________________________
Address__________________________________________ Phone _______________________
Form Updated 08/24/16
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