Youth and Family Ministries Medical/Liability Release Form

This form applies to participation in Unity in Lynnwood Youth & Family Ministries programs and activities, including on-site events, off-site events, retreats, transportation, and group activities.

Participant Information

Youth full legal name

Parent / Guardian Information

Parent / Guardian Name

Relationship to Participant

This address will receive a confirmation email

Emergency Contact Information

Emergency Contact Name

Relationship to participant

Please share information that helps us care for the participant safely.

Please check all that apply:

Food allergies Medication allergies Environmental allergies Chronic medical condition Recent illness or injury None of the above

Participant requires emergency self-carry medication (such as an inhaler or EpiPen)

Yes No

All self-carry meds must still be disclosed.

If you checked any box above, please describe details, triggers, accommodations, and anything leaders should watch for.

Medical details (required if any box above is checked)

Please describe all allergies, medical conditions, and relevant details, including:
• specific allergens
• severity
• symptoms to watch for

what response is needed (for example: EpiPen, avoidance, medication)

(If “None of the above” was selected, you may write “N/A.”)

Relevant medical information

Medical Information Affirmation

I affirm that I have shared all relevant medical information that may affect my child’s participation, and that my child is able to participate in Youth & Family Ministries activities with the information and support provided.

Please list all prescription and over-the-counter medications the participant will bring to Unity Lynnwood events.

For overnight events or events where medication management is required, all medications must be turned in to designated Unity Lynnwood leadership at check-in and will be administered according to the instructions provided.

If a medication is taken as needed, please describe:
• what symptoms to watch for
• when the participant should request assistance

Participants who require emergency self-carry medications (such as inhalers or EpiPens) must be identified below.

Date of last tetanus shot:

Medication Information & Authorization

Medication procedures may vary depending on the nature of the event.

Please read and acknowledge the following:

I understand that medication procedures may vary depending on the nature of the event. For overnight events or events where medication management is required, I understand that all prescription and over-the-counter medications must be turned in to designated Unity Lynnwood leadership at check-in and will be administered according to the ins I understand that participants may not self-administer medications during overnight events, except for approved emergency self-carry medications (such as inhalers or EpiPens), which must be disclosed in advance.

Over-the-Counter Medication Preferences

Please indicate any medications you do NOT authorize Unity Lynnwood leadership to administer.
If no boxes are checked, all listed medications are authorized.

I DO NOT authorize: Aspirin Acetaminophen (e.g. Tylenol) Nasal decongestant (e.g. Sudafed) Pepto-Bismol Ibuprofen (e.g. Advil, Motrin) Cough suppressant (e.g. Robitussin, menthol cough drops) No restrictions

Additional Information to Support Care (Optional)

Please share anything else that would help Unity Lynnwood leadership support your child’s well-being and participation.

Examples may include:
• sensory sensitivities or accommodations
• emotional or mental health considerations
• sleep-related needs
• mobility or physical supports
• dietary needs not related to allergies

(This information will be kept confidential and shared only with leadership as needed.)

Emergency Medical Authorization

I authorize Unity Lynnwood leadership to seek emergency medical care for my child if needed during participation in Youth & Family Ministries activities, including off-site and overnight events. I understand that reasonable efforts will be made to contact me or the emergency contact listed.

Yes No

Physican & Insurance Information

Family Physician (name/telephone)

Medical Insurance (company, policy and ID number) or upload pictures of insurance card below (front and back)

Upload Insurance Card Photo (front)

Upload (8MB)

Upload Insurance Card Photo (back)

Upload (8MB)

Participation, Transportation & Off-Site Activities

Unity Lynnwood activities may include travel away from the church site.

Parental Consent for Minor

Please review & confirm by checking each box

I give permission for my child to participate in Unity Lynnwood Youth & Family Ministries programs and activities during the current program year. I understand that activities may include off-site events and travel, and that details for specific events will be communicated in advance. I affirm that I am familiar with the general purpose of Youth & Family Ministries programming and consent to my child’s participation. I understand that if my child must be sent home due to medical or behavioral concerns, I may be responsible for transportation.

Risk Acknowledgment & Emergency Medical Authorization

Please review & confirm by checking each box

I understand that participation in Unity Lynnwood Youth & Family Ministries activities may involve inherent risks, including travel and physical activity, and I voluntarily consent to my child’s participation. I authorize Unity Lynnwood leadership to seek emergency medical care for my child if needed, including medical, dental, or surgical treatment. I understand that reasonable efforts will be made to contact me and that I am responsible for medical costs not

Confidentiality & Information Sharing

Please review & confirm by checking each box

I understand that medical and personal information provided on this form will be shared only with Unity Lynnwood leadership, staff, and medical professionals as needed to support the safety and care of my child, and will not be publicly released.

Typed names serve as legal consent.

By entering my name in the box below, I am providing my digital signature for the Medical Liability and Release Agreement related to Youth and Family Ministries activities.

Youth and Family Ministries Medical/Liability Release Form - YOUTH (2025-2026)

Description

Youth and Family Ministries Medical/Liability Release Form - YOUTH (2025-2026)

Description

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