ACTS Youth Event Permission & Medical Release Form 2026

This form is effective immediately and will remain in effect until the end of the 2026 year, your information changes, or permission is revoked.

This also acts as a permission slip for your student to attend FINE ARTS DISTRICT'S TRIP IN WOODBRIDGE, VA, ON FRIDAY, APRIL 24 - SUNDAY, APRIL 26, 2026.

Your name *

Email address *

STUDENT INFO

STUDENT NAME *

STUDENT'S CELL PHONE NUMBER

Birthdate *

Gender *

Grade *

MEDICAL INSURANCE

MEDICAL INSURANCE COMPANY NAME *

MEDICAL INSURANCE ID#/POLICY# *

NAME OF POLICY HOLDER *

MEDICAL INSURANCE GROUP NUMBER

IF APPLICABLE

MEDICAL HISTORY

Known Allergies *

Please list all known allergies including but not limited to: Pollen, Medication, Food, etc.

MEDICAL OR SPECIAL NEEDS: *

If none, write "none"

CURRENT MEDICATIONS AND DOSAGE *

If none, write "none"

HEALTH NOTE *

Does your child have any other health related issues we should be made aware of?

PARENT/GUARDIAN INFO

PARENT/GUARDIAN'S NAME *

Phone number *

PARENT/GUARDIAN'S CELL PHONE NUMBER

Address *

PARENT/GUARDIAN'S ADDRESS

ADDITIONAL EMERGENCY CONTACT

EMERGENCY CONTACT'S NAME & RELATIONSHIP TO CHILD *

EMERGENCY CONTACT'S CELL PHONE NUMBER *

CODE OF CONDUCT

1. Safety & Prohibited Items

Possession or use of alcohol, drugs, tobacco, or vaping devices is not allowed.
Weapons of any kind, knives, fireworks, explosives, and lighters are prohibited.
Fighting or any form of physical aggression is not permitted.

2. Transportation

Students are not permitted to drive during the trip or transport other students.

3. Modesty & Media

Clothing must be appropriate and modest: no explicit, sexual, violent, or revealing attire.
- Girls: no crop tops, low-cut shirts, shorts with an inseam shorter than 3 inches, or bikinis.
- Boys: shirts must be worn at all times; swimwear must be appropriate, no excessively tight clothing and swim trunks.
Viewing or sharing explicit or pornographic content is not allowed.
Taking of immodest photos or videos of yourself or others is not allowed.
Phones must be silenced and put away during designated times (leaders can define times).
Leaders may ask students to put phones away at any time and/or collect them to be returned at the end of the trip

4. Relationships & Boundaries

No physical displays of affection (PDA).
No students alone one-on-one with another student- must be in groups of at least 3 or more at all times.
Students must remain in their assigned sleeping quarters after lights out.
No entering the rooms or sleeping areas of the opposite gender

5. Respect & Conduct

Show respect for all people, including fellow students, leaders, staff, and host venues.
Respect given quiet time and lights out times
No foul or obscene language

6. Participation & Expectations

Active participation in all group activities is expected.
Students must follow all event schedules and instructions from leaders.
Be where you are supposed to be, when you are supposed to be there.

Students who fail to comply with these expectartions may be sent home at their parents' expense.

STUDENT SIGNATURE *

I, the student, have read the Code of Conduct and agree to abide by them. I have read the record of my health and give my permission to participate in youth group activities. (Typing your name is equivalent to a physical signature.)

PARENT/GUARDIAN AGREEMENT

TRIP PERMISSION *

By marking this box, I agree to let my child participate in the FINE ARTS DISTRICT'S TRIP IN WOODBRIDGE, VA, ON FRIDAY, APRIL 24 - SUNDAY, APRIL 26, 2026.

MEDIA RELEASE *

Photos and videos may be taken during youth trips for promotional and ministry purposes. Do you grant permission for your child’s image and likeness to be used for these purposes?

Yes

Other

PARENT/ GUARDIAN RELEASE

My child has my permission to attend all youth activities sponsored by Walnut Grove Assembly of God (ACTS Youth) until the end of the 2026 year, my information changes, or permission is revoked.

I, the undersigned parent or legal guardian, acknowledge that participation in church youth activities, including travel and group events, involves inherent risks such as injury, illness, accidents, or property loss. I voluntarily assume all such risks, including those that may arise from the negligence of Walnut Grove Assembly of God, its staff, volunteers, or partnering ministries.

In consideration of my child’s participation, I release, waive, and discharge Walnut Grove Assembly of God and its representatives from any and all liability, claims, or causes of action arising from any injury, illness, damage, or loss related to this event.

I authorize necessary medical treatment for my child in an emergency and consent to care provided by licensed medical personnel. I agree to be financially responsible for any medical expenses not covered by insurance, confirm that my child’s insurance is current, and will arrange transportation home at my expense if required. I further agree to indemnify and hold harmless Walnut Grove Assembly of God and its representatives from any related claims, demands, or suits for damages arising from the giving of such consent.

In addition, I agree to the expectations set forth in the Code of Conduct.

Parent Signature *

By typing my name below, I acknowledge that I have read, understand, and agree to this legally binding agreement.