Medical Release Form for Student Ministry

Student's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
I, Parent or Legal Guardian * the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of Calvary Baptist Church's Student
Ministry, both on and off Church grounds, including the necessary transportation to and from these events and activities.

Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well- being of the child affected; (3) I cannot be personally contacted.
I further agree not to hold Calvary Baptist Church of Oak Ridge or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless Calvary Baptist Church of Oak Ridge for all claims made and liabilities assessed against them as a result of any event or activity. I release Calvary Baptist Church of Oak Ridge and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity. I also understand that COVID-19 is a highly contagious virus and I will not hold Calvary Baptist Church of Oak Ridge staff members, volunteers, or participants responsible if the virus is contracted or exposure takes place.

Furthermore, I understand and assume the expenses of any property damage cause by my child. Should it be necessary that my child be returned home due to disciplinary action, I will be contacted by the leaders and will be responsible to pick my child up and assume the cost of transportation.

I, Student's Name* the undersigned student do hereby agree to respect and obey the rules set forth by Calvary Baptist Church of Oak Ridge Minister of Students or any of its paid staff or volunteers responsible during the event.
By signing below, I am acknowledging that I have read through and understand the above statements.
Signature of Student*

Clear
Todays Date

MonthDayYear
Date
Signature of Parent or Guardian

Clear
Todays Date

MonthDayYear
Date

Emergency Contact Information
Emergency Contact's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Teen:*
A Second Emergency Contact's Information*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Teen*

Medical Information
Physician*
Phone Number*
Please enter a valid phone number.
Medical Insurance Company*
Policy Number*
Member's Name*
Allergies or Medications *
Other*
Please attach a copy of Insurance Card.*

Cancelof
Should be Empty:

Emergency Contact Information

Medical Information