Parent & Student Info

    Please fill out this form to allow your child to participate in youth events, provide medical authorization for your child should it become necessary, and to provide a general waiver for the church in case something should happen during an activity.


    Medical Information


    Terms & Conditions

    My child has my permission and consent to attend and participate in youth activities sponsored by the Dalraida church of Christ (hereinafter "Dalraida") located at 3740 Atlanta Highway, Montgomery, Alabama, and promoted by Jared Kelly (hereinafter “youth minister”) or any other members of Dalraida.

    I understand that travel is sometimes necessary and part of these activities and I hereby consent for my child to ride with the youth minister and/or other adult chaperone from Dalraida on the church bus or in private vehicles should it be necessary for any activity.

    I will assume full responsibility for my child’s behavior during any activity and will make sure that my child follows all rules that have been established by the youth minister or other adult chaperone from Dalraida for any activity or event. I understand that any violation of these rules by my child may result in a phone call and, if necessary, immediate pick-up of my child from the activity or event.

    I hereby authorize and appoint the youth minister and/or his agents, representatives, or assistants who are 18 years of age or older, who supervise the activities at Dalraida into whose care my child has been entrusted, to consent to medical care or dental care, or both, for my child in my absence.

    The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a licensed physician and surgeon for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a licensed for my child.

    I further authorize the youth minister and/or his agents, representatives, or assistants who are 18 years of age or older, who supervise the activities at Dalraida to receive physical custody of my child, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the youth minister and/or his agents, representatives, or assistants who are 18 years of age or older, who supervise the activities at Dalraida.

    It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority and power on the part of the youth minister or his authorized designee, in the exercise of his best judgment, upon advice of such physician, dentist, and surgeon, may deem advisable.

    I hereby provide the forgoing medical information to be used in exercising any decisions related to my child under this authorization

    I agree to exempt and relieve Dalraida, its officers, agents, servants, and/or employees from liability for personal injury, property damage, or wrongful death of my child caused by any act of negligence of Dalraida and/or and its officers, agents, servants, or employees.

    For and in consideration of permitting my child to participate in any activity, using any facility or equipment of Dalraida, and engaging in and/or receiving instruction in any activity, some of which may involve known or unknown dangers or risk of bodily injury, I hereby voluntarily and absolutely release, discharge, waive, and relinquish any and all loss or damages, actions, or causes of action for personal injury, property damage, or wrongful death occurring my child as a result of using facilities or equipment of Dalraida, or engaging in or receiving instructions in any activities some of which may involve dangers and risk of bodily injury or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue.

    I agree, on behalf of myself, my heirs, executors, administrators, or assigns, that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against Dalraida or its officers, agents, servants, or employees, that I will indemnify and hold harmless Dalraida and its officers, agents, servants, or employees from any and all claims or causes of action by my child or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will I present any claim against Dalraida and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by Dalraida and said persons.

    I hereby attest that I have read this release, knowingly waive any other advisement on the potential dangers/risks for my child when engaging in activities at Dalraida, assume all risks to my child associated with activities at Dalraida, and am fully aware of and understand the terms and the legal consequences of signing this release. I knowingly and intentionally agree to this complete and unconditional release of all liability to the greatest extent allowed by law against Dalraida. I also agree that if any portion of this release is held invalid, it is agreed that the remainder shall, notwithstanding, continue in full legal force and effect.