• Centerpoint Student Medical Release Form

  • Please complete the following information for youth involved in Student Ministry activities at Centerpoint Church. This form is for the purpose of use in emergency situations. It gives us your permission to seek whatever medical attention is deemed necessary for your child, and releases Centerpoint Church and its staff of any liability against personal losses of named child. In case of an emergency, all efforts will be made to immediately contact the student's parents or legal guardians before any treatment is executed. The information provided in this form will be good for all Centerpoint student events for one year. Should medical information change for your child, please update this information.
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -
  • Emergency Information

  •  -
  •  -
  •  -
  •  -
  • In case of an emergency, I understand that Centerpoint Church, through the designated person in charge, will first attempt to notify me or the alternate emergency contact listed. In the event these people cannot be reached, I hereby grant permission to the physician or hospital selected by Centerpoint Church, or the person in charge, to provide medical treatment for my child as deemed necessary and rendered by or under the general or special supervision of any licensed physician or medical staff of a licensed hospital. 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. It is further understood that the undersigned will assume full financial responsibility for all expenses incurred for any of the foregoing services. This authorization is given in advance of any required care to empower the agent to give consent for such treatment as the physician may deem advisable. I understand that there are inherent risks involved in any ministry event, and I hereby release Centerpoint Church, its pastors, employees, and volunteers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s involvement. I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I also agree to bring my child home at my own expense should they become ill.

  • Clear
  • We expect each student to adhere to these rules of conduct
    No possession or use of alcohol, drugs, or tobacco
    No students can drive to Centerpoint Student events outside the Middle GA area
    No fighting, weapons, fireworks, lighters, or explosives
    No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
    Participation with the group, and adherence to rules and schedules, is always expected
    Respect property, one another, staff, and adult volunteers.

    *Students who fail to comply with these guidelines may be sent home at their parents’ or legal guardians’ expense.

    The student named above has my permission to attend Centerpoint Student activities sponsored by Centerpoint Church and to ride in our church vans and buses for all activities and events. I the undersigned have legal custody of the student named above.

    I understand that the adults supervising Centerpoint Church youth events retain the right to send my child home from an event if the student does not adhere to basic trip guidelines. I further understand that I will be liable for any transportation expenses incurred in accordance with this policy. Moreover, I understand that I will be notified prior to my child being sent home, and from the moment my child departs from the location of the event, whether in public or private transportation, he or she will be my responsibility.

  • Clear
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm