Plymouth Covenant Church Student Ministry Annual (2023-24) Medical Release and Permission Form

Student Name*

First NameMiddle NameLast Name

Age*

Birthday*

Date

Grade during the 2023-24 School Year:*

School during 2023-24 School Year:*

Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number*

Area CodePhone Number

Student Cell Phone - ONLY INCLUDE IF STUDENT HAS A CELL

Area CodePhone Number

Student Email - ONLY INCLUDE IF STUDENT HAS AN EMAIL

example@example.com

Parent Name:*

First NameLast Name

Parent Cell Phone:*

Area CodePhone Number

Parent Email:*

example@example.com

Parent Name:

First NameLast Name

Parent Cell Phone:

Area CodePhone Number

Parent Email:

example@example.com

Preferred Email for communications:*

If parents cannot be reached in an emergency, alternate contact and relationship to student:*

Name and Relationship to student

Alternate Contact Phone Number:*

Area CodePhone Number

For your student's safety and our knowledge, is *

Does your student have allergies to:*

If so, please list which ones:

Does your student suffer from, or has ever experienced, or been treated currently for any of the following:*

Has your student had a tetanus shot?*

YesNo

Date of last tetanus shot:*

Date

Does your student wear:

Medications currently taking (please list name and dose):

Special instructions for Medications:

Any restriction for student?

YesNo

If yes, please explain:

Medical Insurance Company:*

Medical Insurance Phone Number:*

Area CodePhone Number

Policy #:*

Physician:*

Physician Office Phone Number:*

Area CodePhone Number

For your information, we expect each student to conform to these standards of conduct:

No possession or use of alcohol, drugs, or tobacco.
No students can drive other students without parental consent either verbal or written (adult leader confirmed).
No fighting, weapons, fireworks or explosives.
No offensive or immodest clothing (can be seen up, down or through or underwear overtly visible).
No boys in girls' sleeping quarters and no girls in boys' sleeping quarters.
No electronic devices except cell phones if parents require (not for casual use or text messaging).
Participation with the group is expected.
Respect property.
Respect one another, staff members, and adult leaders (verbally and physically).
Respect and comply with event schedules.

Students who fail to comply with these expectations may be sent home at their parents' expense.

I, the parent(s) have read the rules of conduct and the above evaluation of my student's health. I/we hereby authorize my son/daughter to participate fully in all events sponsored by the Student Ministries at Plymouth Covenant Church during the dates listed above. In the event that medical treatment is required, I/we give permission to the group leaders, counselors, and/or qualified medical personnel to make a decision regarding treatment for illness, injury or emergency care for my child.

I/we agree that I/we am/are solely responsible for all medical costs associated with any accident or injury involving my child during events and travel to and from events. I/we agree that neither the Evangelical Covenant Church, The Northwest Conference, nor Plymouth Covenant Church, nor any agents, volunteers and/or employees associated with events will be held liable on account of my child. I/we also authorize Plymouth Covenant Church to utilize pictures and video taken of my child for promotional purposes, including posting event pictures to PCC's website or PCC's social media.

Parent Signature*

Date

Some events will require separate registration forms to be filled out. The Standards of Conduct are in place to make PCC the safest possible place for all students to come, belong, get equipped and be sent out for ministry.

Activities may include, but are not limited to: all-nighters, overnighters, small group outings, service projects, cookouts, boating, water skiing, basketball, roller-skating, rollerblading, soccer, broomball, volleyball, softball, baseball, frisbee, hiking, biking, concerts, Bible Studies, miniature golf, hayrides, guys/girls night out, etc.

Note: If you desire to limit your student's participation in any event, please write them out below:

Plymouth Covenant Church Student Ministry Annual Medical Release and Permission Form

Medical History

Code of Conduct