2021 Parkgate Student Ministry Medical Release Form

Student Medical Information
Date of last Tetanus injection:
Does your child have any health concerns we should be aware of? (Allergies, dietary restrictions, behavioral concerns, etc.)

Yes No
Please provide additional information on your child's medical needs.
Does your child take any medication?

Yes No
Please provide additional information on your child's medications, including name, dosage, times to be given, and any side effects we should be aware of.
Primary Care Physician:

First Name Last Name
Primary Care Physician Phone Number:

Area Code Phone Number

Health Insurance Information
Health Insurance Company:
Policy Number:
Group Number:
Insured Parent/Guardian Name:

First Name Last Name
Please upload a photo of the front of your health insurance card.

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Cancel of
Please upload a photo of the back of your health insurance card.

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Cancel of

Parent/Guardian Release Statement
By typing my name in the box below, I do hereby give consent to any medical, dental, or surgical treatment that the Parkgate Student Ministry Pastor and/or Adult Leaders from Parkgate Community Church, 3715 Preston Road, Pasadena, TX 77505 may deem necessary while participating in the below mentioned Parkgate Student Ministry sponsored activity. I understand that every conceivable effort will be made to contact me, the parent or legal guardian of the above mentioned student, before treatment is given. I do hereby assume all risks and I agree to release and hold harmless Parkgate Community Church of Pasadena, TX, its representatives, employees, and all related entities from any liability, loss or damage actions, claims and demands, which my child now has or that may arise from their participation in this activity.
Parent/Guardian Electronic Signature: *

First Name Last Name
Parkgate Community Church will be photographing/filming students throughout the year. By typing my name int he box below, I understand that my children's photographs may be presented in an array of multimedia formats both online and in print. This includes our Facebook Page, where I may be taggged.
Parent/Guardian Electronic Signature: *

First Name Last Name

Behavioral Responsibilities Contract
By typing my name in the box below, I agree to uphold the behavioral expectations articulated by the Associate Pastor for Student Ministries at the start of each event I attend.
Student's Electronic Signature: *

First Name Last Name
By typing my name in the box below, I state that I understand that if my child is in violation of any of the aforementioned behavioral expectations, upon the decision of the Pastor of Student Ministries of Parkgate Community Church with consultation from another Student Ministry Staff member or the Senior Pastor, may be sent home at my expense.
Student's Electronic Signature: *

First Name Last Name
Parent/Guardian Electronic Signature: *

First Name Last Name
Should be Empty:

Basic Contact Information