Grace Student Ministry Activity and Medical Release
Please fill out this form and click submit.
Participant Name
*
Sex
*
Please select all that apply.
Male
Female
Parent or Guardian Name
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Parent or Guardian Email
*
This address will receive a confirmation email
Parent or Guardian's Phone
*
Participant's Phone (optional)
Participant's Birthdate
Participant's Age
*
General Release: I give permission for my child (named above) to attend all supervised events, field trips, and service projects associated with Grace Community Church. Further, I give permission for my child to be transported to and from events by hired and volunteer drivers authorized by Grace Community Church.
*
Please select all that apply.
Yes
No
Medical Authorization and Custody Release: In the event of an emergency and I am unable to respond, I authorize the leaders or staff of Grace Community Church, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical/dental treatment and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care, under the supervision and upon the advice of a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act, for my child. I understand that I am responsible for payment of treatment. I further authorize the leaders of Grace Community Church to receive physical custody of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to said adult.
*
Please select all that apply.
Yes
No
Photo Release: My child can be photographed. (Photos may be used for documentation and promotion of student ministry events, such as church promotional material, church website and Church Facebook page.
*
Please select all that apply.
Yes
No
Emergency Contact Name
*
Emergency Contact Phone
*
Doctor's name and Phone
*
Medical Insurance Company
Policy / Group Number
Name of Policy Holder
Dentist Name
Dentist Phone
Dental Insurance Company
Policy / Group Number
Policy Holder Name
Allergies: Please list any allergies to drugs, foods, plants, insects, etc:
*
Medications: Please list any prescription medication to be taken by the participant (including what it is taken for, when it is to be taken, dosage information, and any special procedures):
*
Please list any non-prescription (over-the-counter) medication you do NOT want dispensed to your child:
*
Please list any additional information relevant to participating in youth activities (dietary needs; surgeries or serious injuries; chronic or recurring illness; medical conditions such as epilepsy or diabetes; mental health concerns, learning disabilities, any restrictions, etc.):
*
Any specific activities to be restricted:
Reason for restriction:
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Description
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