Grace Student Ministry Activity in Medical Release / Behavior guidelines
Please fill out this form and click submit.
Participant Name
*
Activity
Parent or Guardian Name
*
Parent or Guardian permission
*
Please select all that apply.
I permit my child to attend this activity
yes
no
Parent or Guardian Email
*
This address will receive a confirmation email
Parent or Guardian's Phone
*
Participant's Phone (optional)
Participant's Gender
*
Please select all that apply.
Male
Female
Participant's Birthdate
Participant's Age
*
Address
*
--
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
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 Student Ministry Facebook page.
*
Please select all that apply.
Yes
No
Emergency Contact Name
*
Emergency Contact Phone
*
Physician Name
Physician Phone
Date of last Tetanus shot
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:
Behavior Expectations: In general, there are two main rules: love God and love others (Mark 12:30-31). If something doesn’t glorify, God don’t do it. We want to live lives worthy of the gospel of Christ. (Phil 1:27). Here are some more specific rules: 1. Honor Authority - Follow instructions from the Youth Pastor and adult leaders without complaining or arguing (Phil 2:14). 2. Respect Others- Be considerate of others and respect them (1Pet. 2:13). No harming other students. No bullying (physically, verbally, or digitally). Use speech to build others up (Eph. 4:29). • No public displays of affection (i.e. touching where there is underwear/private areas, kissing, being on top of other youth, hugging, etc.) Side hugs are ok. 3. Fight Sin! (Gal. 5:16) Do not possess, use, or consume alcoholic beverage(s), any illegal substance(s), or tobacco in any form. If suspicion of any of these occurs, the Youth Pastor or adult supervisor may search person, room, luggage and/or personal belongings. • Adhere to a modest dress code. This includes swimwear. • No pornographic or sexually explicit content is allowed in any form. • No coarse joking or foul language is allowed in any form. 4. Technology Phone use is under the discretion of the Youth Pastor. If allowed, phone use must be minimal or for emergencies only. If phones become a problem, the Youth Pastor will take them. 5. Stay with the group • Don’t go off by yourself. Students must use the buddy system. • Adult leaders must always supervise students. To support the purpose of this trip/activity and to uphold the group goals, I (the participant) and I (the parent or legal guardian) understand that the following consequences will result if the participant violates the above rules: A verbal warning. A loss of privileges. Call to parents and student may be sent home at parent’s expense. (Parents agree to bear expense for child to go home, including picking up your child and taking them home early.)
*
Please select all that apply.
Participant agrees
Parent or Guardian agrees
Signature of Parent or Guardian
*
Signature of Participant
*
Date
*
Submit
Description
Please fill out this form and click submit.
×
Please Fix the Following
