The Pentecostals of The Woodlands

General Contact Information

Student's First Name

Student's Last Name

Parent or Guardian's First Name

Parent or Guardian's Last Name

Mobile Number

Emergency Phone Number

Parent or Guardian's Address

Address 1

Address 2

Country

City

State

Zip/Postal Code

Medical Information

Is your student presently being treated for an injury or sickness or taking any medication?
Yes
No

If your student is being treated for an injury or sickness or taking any medication, please explain. If this is not applicable, put the response "N/A".

Does your student have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity?
Yes
No

If your student has a physical handicap or illness that would prevent him or her from participating in normal rigorous activity, please explain. If this is not applicable, put the response "N/A".

Does your student have allergies? If so, please list them below.

Does your youth have, or has your youth ever had, any of the following? Select all that apply.
Asthma
Diabetes
Hay Fever
Heart Murmur
Kidney Disease
Seizure Disorders
None of these apply

If yes, please explain. If not applicable, please respond with "N/A".

Does your student sleepwalk?
Yes
No

What is your student's blood type?

Family Doctor's Name

Doctor's Phone Number

Insurance Company

Insurance Policy Number

Consent and Certification

I, the undersigned, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities of The Pentecostals of The Woodlands of The Woodlands, Texas, and any other supervised activities customarily associated with its youth group, including youth rallies and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events. If I wish to revoke this consent for any reason, I will promptly notify the pastor in writing.

Medical Treatment Authorization

I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my youth is injured or becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my youth, if required by law or a health care provider: Tim Szumanski, Mindi Szumanski, another adult chaperone designated by the pastor, and

Church Representative's First Name

Church Representative's Last Name

(Note to Parent: you may add or delete a name as desired.) I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that The Pentecostals of The Woodlands will not be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the pastor in writing of any health changes that would restrict my youth’s participation in any normal youth activities. I also understand that the pastor and designated adult chaperones reserve the right to restrict my youth from any activity that they do not feel is within the physical capabilities of my youth.

Photography Consent

I understand that my child(ren) whose name is listed above may be photographed at the youth events or activities. I understand that these photographs may be used in promoting youth and POW-related events, either in print or on the Internet.

I consent to the participation of my child in children’s activities conducted by The Pentecostals of The Woodlands. I certify that my child is physically fit and adequately prepared to participate in this event.
Yes
No

I consent to my student being photgraphed.
Yes
No

Please type your full name below as a declaration of consent.

Youth Consent Form

Youth Consent Form

General Contact Information

Parent or Guardian's Address

Medical Information

Consent and Certification

Medical Treatment Authorization

Photography Consent

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