SHILOH STUDENT MINISTRY

The undersigned, being the parent or legal guardian of the minor child named above, do hereby authorize the staff members, agents, and employees of Shiloh Road Church of Christ to photograph or film my student. The undersigned, being the parent or legal guardian of child, do hereby authorize the staff members, agents, and employees of Shiloh Road Church of Christ to photograph or film my student. The undersigned authorizes Shiloh Rd Church of Christ permission to the use and display any said photographs and/or videos in publications, multimedia productions, displays, advertisements, training materials, or internet publication related to the promotion of Shiloh Rd Church of Christ or in the promotion of any activities supported by Shiloh Rd Church of Christ. The undersigned agrees that Shiloh Rd Church of Christ may use name and likeness supplied by the undersigned. The undersigned releases and forever discharges Shiloh Rd Church of Christ and its staff members, agents, and employees from any and all claims and demands arising out of or in connection with the use of said photographs/images, including but not limited to, any claims for invasion of privacy or defamation.

The undersigned hereby gives permission for my student named above ("Participant"), to attend and participate in any Shiloh Road Church of Christ Student Ministry (SSM) activities,events, and retreats during the period of October 1, 2024 - September 30, 2025.

LIABILITY RELEASE: In consideration of Shiloh Road Church of Christ allowing the Participant to participate in SSM (Class, Activities, Events, Retreats, Lock-Ins, Trips), I, the undersigned, do hereby release, forever discharge and agree to hold harmless Shiloh Road Church of Christ, its ministers, elders, employees, volunteers, and teachers (collectively herein the "Church") from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in SSM activities. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in the SSM activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned student pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my student to return home due to medical reasons, disciplinary action, or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my student to ride in any vehicle driven by an approved and licensed ADULT chaperone while participating in activities sponsored by Shiloh Road Church of Christ. My student and I agree that SEAT BELTS MUST BE WORN AT ALL TIMES during transport.

My student and I have both read and agree to the above mentioned.

It is the parent/guardian 's responsibility to inform adult leaders of any medical changes throughout the year. Please text a photo of the health insurance card to Melody to include with this form. 

List all medications the student will take during any SSM trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements, and vitamins. Students are required to give all prescribed medication to the adult leader in their original containers with complete dispensing instructions before the start of the event. Students are not permitted to carry prescribed medication UNLESS A PARENT/GUARDIAN gives consent to the adult leader.

Over-the-Counter Medication Permission: Do you give permission for your student to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at an SSM event?

MEDICAL CONDITIONS: Please answer in detail or write N/A. Use back of page, if necessary.