Thrive Center - General Permission Slip / Medical & Liability Release Form

Thrive Teen Centers Inc.

1511 South Street, Leesburg, FL 34748
352-431-3981
Please provide the student's full name and email. This must be completed with a parent or guardian present.*

Your name *

Email address *

RULES

1) Age Limit:
Open to all youth 11 – 17 years age OR 6th – 12th grade. Adults (18 years & older) are not allowed except for Thrive staff and parents/guardians of children in attendance.

2) Dress-Code:
No revealing or provocative clothing (including offensive images/words). Footwear & shirts are required.

3) Health/Safety:
No alcohol, cigarettes, tobacco, drugs, drug paraphernalia, weapons (of any kind), fireworks, explosives (of any kind), air-soft guns/ammo, laser pointers, etc.

4) Behavior:
- No foul, inappropriate or derogatory language.
- No cut downs, fighting, bullying, intimidation or physical threats.
- No skating, biking, running, wrestling or rough play indoors.
- No male-female contact.
- No abusing or misusing property/equipment – must treat with care.
- No going onto neighbor’s property or climbing on/over walls.

5) Obey the Staff:
Respect for Thrive staff is mandatory. All youth must obey Thrive staff.

6) No disrespectful language, behavior or attitude allowed. Staff may kick-out or refuse entrance to anyone as necessary to uphold good order, health & safety.

7) Responsibilities:
- Check-in first thing each visit at snack bar counter.
- Each youth is responsible for his/her own property. Thrive is not responsible for lost/missing items.
- Have a good attitude.

Additional Rules:
• No loitering outside after dark on Thrive/neighboring property.
• No food or drinks on the carpet (water is OK).

I have read and understand the Thrive rules and agree to follow them. I acknowledge that failure to comply may result in removal from the premises.

If you agree, please select the checkbox. If you do not agree, please understand your student will not be allowed on campus.

Phone number *

Birthdate

School

Grade

Gender

Address

Household members

Parents Full Name(s):

Permission Consent:

I (We) give permission for my (our) above named minor to become a member of Thrive Teen Center and complete the Thrive mentorship lessons with an authorized mentor. I (We) understand that the requirement of membership is to complete the Thrive Junior Varsity Course, which is the first three of twelve one-on-one mentorship lessons that are based on Biblical principles of personal value, value of others, etc. The lessons and all other program information are available for my (our) review at Thrive Teen Centers.

I (We) understand that my (our) child will always be under adult supervision while inside the Thrive Teen Center but that Thrive Teen Center assumes no responsibility to monitor the minor outside of the confines of the building/property.

I (We) understand that all of the adults working with Thrive Teen Center are volunteers and that any assistance, tutoring, or counsel they may offer is not intended to replace any needed professional help.

Please review the terms above and confirm your agreement.

Medical Emergency & Release of Liability:

Medical Emergency & Release of Liability:
I do hereby release, forever discharge and agree to hold harmless Thrive Teen Centers Inc. and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whosoever which may be incurred by the undersigned and the participant that occur while said person is participating in trips or activities including recreation and work activities. I further consent to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify said teen center/church, its directors, employees and agents for any acts malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.

I (We) do hereby release any licensed physician and/or medical provider from any liability in the proper treatment of my (our) minor. Furthermore, I (We) hereby authorize the treatment of my (our) minor and agree to pay all reasonable medical costs.

Please review the terms above and confirm your agreement.

Medical Insurance Company:

Please list the following information:
1. Medical Insurance Company

Medical Insurance Company:

Please provide important medical details, including allergies and current medications.

In Case of Emergency - Parent/Guardian Name *

Please list the student's Parent(s) or Guardian Name(s).

In Case of Emergency - Phone Number *

Please provide the phone number of the person listed above.

In Case of Emergency - Email

Please provide the email of the person listed above.

Are you currently attending a local church? *

Are you involved in their youth group?

Please select yes or no.

Student Signature: *

Please type the student's full legal name.

Parent's /Guardian's Signature: *

Please type the Parent's /Guardian's full legal name.

What is today's date? *

Please select today's date.

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