Crosspoint Youth Group Release Form Please enable JavaScript in your browser to complete this form. - Step 1 of 8I am ... *Registering my child for the first time.Extending consent for a child already registered.NextName of Youth *FirstLastBirthdayGenderMaleFemaleOtherAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOnly update the address and contact information below if something has changed in the past year.Update AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeYouth's Phone NumberTXT OK?YesNoYouth's EmailPreviousNextPrimary Contact *FirstLastRelationship *Phone *TXT OK?YesNoEmail *PreviousNextSecondary Contact Update? *Yes, I'd like to update thisNo, this information has not changedSecondary Contact *FirstLastRelationship *Phone *TXT OK?YesNoEmail *PreviousNextEmergency Contact Update? *Yes, I'd like to update thisNo, this information has not changedEmergency Contact *FirstLastRelationshipPhoneTXT OK?YesNoEmail *PreviousNextHealth Insurance Provider Update? *Yes, I'd like to update thisNo, this information has not changedHealth Insurance Provider *Policy NumberPhonePlease 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 for each FYRE activityAcetaminophen (Tylenol)IbuprofenAspirinCough Drops/MedicineTumsNyquil/DayquilOtherOther Medicine(s)PreviousNextUpdating preview…This is a preview of your submission. It has not been submitted yet! Please take a moment to verify your information. You can also go back to make changes.Is this information correct?No, go backYes, continueI accept responsibility for providing FYRE with any prescription medications that my child may need while they participate in any FYRE functions. I understand that I must hand such medications directly to a FYRE 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 FYRE 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 FYRE 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 Crosspoint Church, its 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 Crosspoint Church and FYRE. 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. RESPONSE REQUIRED *YESNOAs legal guardian of this minor, I grant permission for Crosspoint Church (and FYRE) to publish photos of my child in their various forms of publications or on the church’s websites. I give Crosspoint 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.Signature *Clear SignatureBy signing, 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.Full Name *Please type your name verifying the above signature is yoursPreviousSubmit