Medical & Photo Release Form

Medical & Photo Release Form
Each student must fill out the information below completely. This form will be kept on file for one (1) year as a medical release. If your medical or insurance information changes, please contact the Student Ministry Office or submit another online form to update your information. Form is valid for the year of 2021
Student's Name*
First NameLast Name
Gender*
FemaleMale
Date of Birth*
MonthDayYear
Date
Age*
School*
Grade*
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
List any Allergies or Medical Info your Child has:
Have you been exposed to or experiencing any covid-19 symptoms in the last week or so?
Parent / Guardian Name*
First NameLast Name
Cell Phone Number*
Work Phone Number
Home Phone Number
Emergency Contact (If parents cannot be contacted)*
First NameLast Name
Emergency Contact Phone Number*
MEDICAL RELEASE:
I hereby give my permission, for myself or my child, to participate in an activity organized by the The Workshop Student Ministry /Calvary Chapel Arroyo Grande. I hereby release, hold harmless and absolve Calvary Chapel Arroyo Grande, their pastors, leaders, staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Calvary Chapel Arroyo Grande staff or any adult counselor acting on behalf of Calvary Chapel Arroyo Grande with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate} licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child's medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that Calvary Chapel Arroyo Grande may tape or photograph my child and record his or her Voice during their participation in the activity. I agree that Calvary Chapel Arroyo Grande will be able to use them, in whole or in part. whether In original or modified form in any manner or media, Including without limitation, for the purpose of advertising, promoting, and publishing the Calvary Chapel Arroyo Grande whether doing the activity or thereafter. I hereby release and discharge Calvary Chapel Arroyo Grande and an affiliated entities from any and all claims, demands, or causes of action that I shall in connection with the use and exercise of the rights granted in this release.
Signature*
Clear
Parent / Guardian
Submitted Date*
MonthDayYear
Date
STUDENT COVENANT:
During our youth ministry trips and events, we will be doing our best to live together as a family in Christian community. Family life is based on love, respect, trust, support, and spending time together. Each of us as a member of the family is very important. To create and maintain this atmosphere of family and community, all youth agree to the following covenant.
1. When we travel away from Calvary Chapel Arroyo Grande, we recognize that we are guests of our host organization. As guests, we will be considerate of our host organization and to any leaders who reside there. In the evenings we agree to be inside our sleeping quarters after the hour designated by our leaders/chaperones or whenever the adult volunteers ask us to stay inside.
2. As a member of the Calvary Chapel Arroyo Grande Youth, I will:
- be responsible for my own belongings and respect the property of others.
- participate fully in the events of the youth ministry trips and events.
- be respectful of the adult leaders and their decisions.
- especially care for and respect property of the church and of the host organizations
- use the “buddy system” in addition to telling an adult of my whereabouts at all times.
- be responsible in my expressions of care, concern, and intimacy.
- not bring or use illegal substances such as tobacco, drugs, or alcohol.
3. As participants in this youth group, I recognize that I am joining a Christian family and community. I agree to abide by this covenant while I am a member of this community. I understand that if I break this covenant, my parents may be notified and that I may be sent home at my parents’ expense.
I hereby agree to adhere to the above covenant:
Student Signature*
Clear
Parent / Guardian
Submitted Date*
MonthDayYear
Date
Should be Empty: