FC Fullerton Student Ministry Release & Connect Form

Release & Connect Form

Please fill out the following form as accurately as possible. The form respondent MUST be a Parent or Legal Guardian unless the student is at least 18 years old.
Respondent Name (Parent/ Legal Guardian)*

First NameLast Name
Student Info
STUDENT Name*

First NameLast Name
Student Cell Phone Number

Area CodePhone Number
Would you like to receive occasional texts regarding our ministry?*
This is highly suggested
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Birthday*

MonthDayYear
High School Graduation Year*
EX: 2024
Student Gender*
Student Shirt Size
Names & Grades of Student's Siblings
EX: John Smith - 10th
Parent/Legal Guardian(s) Info
Parent/Legal Guardian #1 Name*

First NameLast Name
Mom Cell Number*

Area CodePhone Number
Mom Email*
example@example.com
Would you like to receive occasional emails and texts regarding our ministry?*
Parent/Legal Guardian #2 Name

First NameLast Name
Dad Cell Number

Area CodePhone Number
Dad Email
example@example.com
Would you like to receive occasional emails and texts regarding our ministry?
Medical Info
Family Doctor's Name
Family Doctor's Contact Information
Does the student have medical insurance?

YesNo
Insurance Company
Policy or Group #
Known Medical Conditions or Allergies
Current Medications and Dosages
Other Medical Notes
Date of last tetanus immunization

MonthDayYear
Does the student use contact lenses?

YesNo
Will you allow blood transfusions?*

YesNo
RELEASE & CONSENT

Agree to the following 4 Release & Consents before participating in our functions
AUTHORIZATION OF CONSENT TO TREATMENT OF A MINOR:

AUTHORIZATION OF CONSENT TO TREATMENT OF A MINOR:*
By checking yes, we the above do hereby authorize Friends Church Fullerton children's/youth ministry leaders as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of, any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis treatment or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.

This authorization is given pursuant to the provisions of Section 25:8 of the Civil Code of California. This authorization shall remain effective through the above named minor's graduation from high school, unless sooner revoked in writing delivered to said agent(s).
Do you agree to the above "AUTHORIZATION OF CONSENT TO TREATMENT OF A MINOR"

YesNo
RELEASE OF FRIENDS CHURCH FULLERTON

By checking yes, we shall indemnify, hold free and harmless, assume liability for, and defend the Friends Church Fullerton, its agents, servants, employees, officers, and directors from any and all costs and expenses; including but not limited to, attorney's fees, reasonable investigative and discovery costs, court
costs, and all other sums which Friends Church Fullerton, assertion of liability, or any claim or action founded thereon, arising or alleged to have arisen out of the child named above use of real or personal property belonging to Friends Church Fullerton, its agents, servants, employees, officers, and directors, or by action or omission by the above named child.
Do you agree to the above "RELEASE OF FRIENDS CHURCH FULLERTON"

YesNo
COVID-19 RELEASE OF FRIENDS CHURCH FULLERTON

An inherent risk of exposure to COVID-19 exists in any place where people are present. COVID-19 is an extremely contagious disease that can lead to severe illness and death. According to the Center of Disease Control and Prevention, people with underlying medical conditions are especially vulnerable. By participating or allowing the above-named child's participation at Friends Church Fullerton Student Ministry functions, you (the respondent) voluntarily assume all risks related to exposure to COVID-19.
Do you agree to the above "COVID-19 RELEASE OF FRIENDS CHURCH FULLERTON"

YesNo
PUBLICATION RELEASE:

Adults: The user acknowledges that participation in the event/s activity/ies described herein also constitutes approval to be photographed and/or videotaped and to have those photographs and/or videos placed in Church related publications, including the Church website.

Parents for Children: Participation in church related event/s, and activity/ies constitutes approval by you the parents for your children to possibly be photographed and/or videotaped and to have those photographs and/or videos placed in Church related publications, including the Church website.
Do you agree to the above "PUBLICATION RELEASE"

YesNo
Submitting Parent/Guardian Signature:*

Clear
Form Respondent Name:*

First NameLast Name
Date*

MonthDayYear
Should be Empty:

Release & Connect Form

Student Info

Parent/Legal Guardian(s) Info

Medical Info

RELEASE & CONSENT