Ignite Youth Consent Form • Impact Church

THIS FORM MUST BE COMPLETED BY A PARENT/ GUARDIAN. THIS FORM MUST BE COMPLETED IN TWO PARTS. PLEASE FILL OUT ONCE FOR THE YOUTH AND THEN ONCE FOR THE PARENT/ GUARDIAN.

Parent/Guardian (Primary Contact)

Youth

First Name *

Last Name *

Name of your child (youth) *

Parent Phone Number *

Parent Email Address *

Date of Birth *

School Grade *

Gender *

Home Address *

Health Card Number (optional)

How did you hear about Ignite Youth?

Home church (if you are part of a church)

As youth leaders, we would love to be able to contact your youth directly at times. If you are comfortable, please fill out their personal contact information

Youth Phone Number

Youth Email Address

EMERGENCY CONTACT:

Emergency Contact First and Last Name *

Emergency Contact Phone Number *

Relationship to Youth *

MEDICAL HISTORY

Please list any medical information Ignite Youth leaders should be aware of *

Please list any known allergies (food, medication, bee's etc..) that Ignite Youth leaders should be aware of *

IGNITE YOUTH CONSENT

I give the above-named youth full consent to attend the activities of Ignite Youth from the date this consent is signed to August 31, 2025 *

Yes

I understand that the Ignite Youth Leaders and Volunteers of Impact Church will take all of the necessary precautions to ensure the safety of my child *

Yes

I hereby release Impact Church from any legal or financial obligation due to the injury of the above named youth. *

Yes

In the event that the above-named youth has need of medical attention, I give permission for the Ignite Youth Leaders and Volunteers of Impact Church to seek medical attention. *

Yes

I understand that every effort will be made to contact me or my alternate responsible party prior to any emergency medical attention. *

Yes

I give Impact Church & Ignite Youth permission to photograph &/or film my child and use his or her picture/video for the church's social media platforms including but not limited to Instagram, Facebook & Youtube, as well as the church's website and marketing materials presently and in the future. *

Yes, you may take my photo/video

No, you may NOT take my photo/video

I give permission for the above-named youth to travel with Ignite Youth in the transportation provided. *

Yes

I understand that I can revoke this consent in writing at any time. *

Yes

By entering your name this serves as a signature signifying your agreement to the above document *

Date *

THIS FORM MUST BE COMPLETED BY A PARENT/ GUARDIAN. THIS FORM MUST BE COMPLETED IN TWO PARTS. PLEASE FILL OUT ONCE FOR THE YOUTH AND THEN ONCE FOR THE PARENT/ GUARDIAN.

As youth leaders, we would love to be able to contact your youth directly at times. If you are comfortable, please fill out their personal contact information

EMERGENCY CONTACT:

MEDICAL HISTORY

IGNITE YOUTH CONSENT

Before clicking submit, click, "add another person," to input information for each youth OR to add another parent/ guardian contact.