SOZO STUDENT MINISTRY PROGRAM

REGISTRATION CONSENT & WAIVER FORM

Please fill out this form in its entirety. If you have more than one (1) child attending our program(s), a form needs to be filled out for EACH child.

Your child will not be able to attend/participate in any programs/activities with SOZO Missions until this form is completed and signed by a parent/guardian.

Child's Full Name

First Name

Last Name

Nick Name (if applicable)

First Name

Last Name

Child's Date of Birth

YYYY

Child's Grade

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Phone Number (if applicable)

(###)

###

####

Parent/Guardian Full Name

First Name

Last Name

Parent/Guardian Phone Number

(###)

###

####

Parent/Guardian Email

Youth Medical Information

Does your child have any condition that would prevent him/her from participating in any activities?

(If yes, please explain below)

Yes

Does your child have ANY allergies or take any prescription medications?

Your child may carry emergency medications and use as prescribed (i.e., inhaler or EpiPen). Anything other than rescue medication must be turned into staff/program leaders. Please complete and include with this form (or if space provides, list below) a list of all medications including dosage, administering guidelines, and any food/drug allergies your child has.

Yes

Has your child been diagnosed with any mental health condition?

(If yes, please explain below)

Yes

Please list any medications taken by your child and/or explain any medical conditions/diagnoses indicated above and/or any other pertinent information that our youth ministry staff/volunteers should know about your child:

Drop Off & Pickup Policy

While the youth ministry offers transportation to/from the youth programs on club nights (for students who live within the local community, in less than a 5mi. radius), it is ultimately the parent’s/guardian’s responsibility to ensure their child is picked up by the contracted times and no later than 9:00pm on the scheduled program nights, unless otherwise stated. If you are unable to pick up your child by the contracted time, alternate arrangements need to be made. In the event a parent/guardian cannot be contacted, it is our policy to call an emergency contact on file. If a parent/guardian or the emergency contact(s) cannot be reached within a reasonable timeframe, authorities will be called to ensure the safety of the child. Late pickups will not be tolerated for any reason. You are expected to pick your child up on time or arrange for an alternate person to pick them up in case of a weather, traffic, or work-related conflict, or any other emergency. .

Parent Consent & Youth Waiver

- I confirm that all the information listed on this form is truthful and accurate. − I give permission for my child to attend the SOZO Kidz/SOZO Youth program at the SOZO Oasis Center (3124 17th St E, Bradenton, FL 34208) and understand that this program is sponsored by SOZO Missions, Inc. − I understand that the SOZO Missions youth ministry is concerned about the health and safety of my child and will follow the guidelines of this form in concerns to my child. − I understand, acknowledge, and agree that in consideration of being allowed to participate in the SOZO Kidz/SOZO Youth program: 1.) I waive any and all claims for injury, illness, or damage against the SOZO Missions staff/volunteers, and the sponsoring agency, which my child may incur while participating in this program; 2.) I assume the risk for any and all injuries, illness, or damage which my child may incur while participating in this program; 3.) In the event of any emergency, I hereby authorize SOZO Missions staff or volunteers as an agent for me, to consent to an x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital; 4.) I grant permission for SOZO Missions Inc., the SOZO Oasis Center and/or any partnering organizations to use any photographs, film, and videos of my child for promotional or other uses either associated with the program or partnering organizations, including use on website(s). .

Parent/Guardian Electronic Signature

I am typing my full name into this box as a representation of my electronic signature, agreeing to all of the terms and policies stated above and confirming that all of the information in this form is true and accurate.

Date of Signature

YYYY