Permission Form & Medical Release

Permission Form & Medical Release
Name of Student (1):*

First & Last NameBirthdayAllergies
Any other information that needs to be known?
Name of Student (2):

First & Last NameBirthdayAllergies
Any other information that needs to be known?
Name of Student (3):

First & Last NameBirthdayAllergies
Any other information that needs to be known?
Name of Student (4):

First & Last NameBirthdayAllergies
Any other information that needs to be known?
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState

Zip Code
Name of Parent/Guardian 1:*

First NameLast Name
Parent Phone #:*
Parent E-mail*
example@example.com
Name of Parent/Guardian 2:

First NameLast Name
Parent Phone #:
Parent E-mail
example@example.com
Emergency Contact (if parents can't be reached):*

First NameLast Name
Emergency Phone:*
Insurance Information:*

Insurance Provider (Blue Cross, Aetna, Medicaid, etc.)Policy and/or Group #
Primary Care Physician:*

Name of PhysicianPhone Number
Permission & Medical Release Consent:
I, the parent(s) or legal guardian(s) of the above student(s), hereby provide express permission for my student(s) to participate in camps, retreats, trips, and other outings sponsored by the Maypearl Church of Christ in Maypearl, TX.

By giving consent, I certify that the student(s) is in a condition of health that will permit his/her participation in such events. I authorize an adult, whose care the minor has been entrusted, consent to medical, dental, or surgical examination and treatment by any licensed physician, dentist, or hospital. I also authorize first aid treatment to be given as necessary. I also recognize and agree to pay all medical treatment or hospital expenses that may be incurred and will indemnify and reimburse Maypearl Church of Christ with respect thereto.

By selecting below, I as the parent(s) or legal guardian(s) release and relieve Maypearl Church of Christ, its agents, employees, youth leaders, and sponsors from any liability related to or arising out of the event or any accident or injury related to the event.
Please Select:*

I, (The Parent/Legal Guardian) Give ConsentI, (The Parent/Legal Guardian) Do Not Give Consent
Picture/Image and Video Release Consent:
Further, I consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the student(s) during their participation in any activity, event, or trip to be used, distributed, or shown as Maypearl Church of Christ sees fit including but not exclusive to: slide shows, church web site, social and print media. (When used in the public realm identifying information will be used responsibly - e.g. names will not be attached to specific pictures or video images on the church's website.)
Please Select:*

I, (The Parent/Legal Guardian) Give ConsentI, (The Parent/Legal Guardian) Do Not Give Consent
Should be Empty:

Permission Form & Medical Release

Permission & Medical Release Consent:

Picture/Image and Video Release Consent: