Student Ministry Release Form

Your name *

Email address *

CHILD INFORMATION

Child's Name *

Grade *

Gender *

Birthday *

Phone number *

Address *

PARENT OR GUARDIAN INFORMATION

Parent or Legal Guardian's Name *

Relation to Child *

Phone number *

Parent Email *

Please provide the email address you use the MOST OFTEN.

NON PARENT CONTACT

Emergency Contact *

Relation *

Phone *

INSURANCE AND MEDICAL INFORMATION

Insurance Number *

Provider *

Provider Phone *

Primary Care Physician *

Primary Care Phone *

Medical note *

Please list all health concerns and medications your child is currently taking

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Faith Church and its staff of any liability against personal losses

I, the undersigned, willingly allow my child to participate in events/programs organized by Faith Church Student Ministry. In the event that he or she is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.

I consent and agree with the statement above *

GUARDIAN RELEASE FOR STUDENT EVENTS

I give permission for my child to participate in all activities planned by Faith Church Student Ministry. This may include trips off Faith Church campus and property during youth group hours. Notices will be sent to parents prior to these activities. I support the Youth Pastor and adult leaders chaperoning these activities, and I give them permission to take reasonable action, as they deem necessary, to protect the best interest of my child.

Parent/Guardian Electronic Signature *

By typing your name below, you are consenting to the above "guardian release for student events."

MEDIA RELEASE

Consent for Media Release *

Please select one

I give my permission for FAITH CHURCH to use my child's picture on their website, social media sites, and for media releases (web and print), in which to advertise a church event.

I DO NOT give my permission for FAITH CHURCH to use my child's picture under any circumstances.

Parent/Guardian Electronic Signature *

By typing your name below, you are affirming the option you selected above in "consent for media release."

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