Student Ministry 2021 Medical Release Form

Student Ministry 2021 Medical Release Form
Student's Name
First NameLast Name
Current Grade
School Student Attends
Student's Email
example@example.com
Student's Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Student's Gender
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Parent/Guardian Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Claims To Be Mailed To
Policy or ID Number
Family Physician
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medications Currently Taking (list all, even vitamins)
List Allergies
Date of Last Tetanus Shot
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Permission to Give
Special Instructions Regarding Student
My child: Student's Name Here may participate in all Church Student Ministry events for the 2021 calendar year. As a parent or guardian, I authorize an adult counselor to make legal decisions, medical decisions, or otherwise concerning said minor during the time of Church Student Ministry events. I also agree that I will immediately notify Church Student Ministry, in writing, of any changes to the information above, medical or otherwise. I hereby release Church and its sponsors of any legal responsibilities and liability in the event of an accident or injury.

As a parent or guardian, I have carefully and truthfully provided all the information requested and give my permission for my child to participate in Church Student Ministry events in 2021.

Both my child and I understand that he/she will be expected to obey the rules, regulations and policies of Church Student Ministry events.
Parent/Guardian Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student Signature
Clear
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: