RStudents Release Form

RStudents | Release Form

Parent/Guardian Name:*

First NameLast Name

Parent/Guardian Name:

First NameLast Name

Parent/Guardian Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Email:*

example@example.com

Parent/Guardian Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Name:*

First NameLast Name

Emergency Contact Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

What is the Emergency Contact's relationship with the child?*

Please list any children participating in RStudents:*

Rows	Name	Age	School	Grade	Gender
Child
Child
Child
Child
Child

YesNo

If no, please give a brief explanation of your living situation:*

YesNo

Please list any medical conditions/medications/allergies for your children:*

YesNo

If yes, please explain:*

A note about medication:

If your student is taking prescription medication with them on any RStudents activity, we must be informed. Our team will keep a record of that information for the duration of the activity which will be kept confidential. RStudents servants will be there to assist if there’s an emergency.

YesNo

If yes, please list your insurance provider:*

Please attach the front of the insurance card for each child:*

Please attach the back of the insurance card for each child:*

YesNo

Family Physician:*

First NameLast Name

Family Physician Phone Number:*

Please enter a valid phone number.Format: (000) 000-0000.

Family Physician Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

RSTUDENTS EVENT PARTICIPATION RELEASE

I/we, the undersigned, hereby grant permission for the participant(s) listed above to participate in RStudents events throughout the year. I/we acknowledge that dates and events can change, but I/we will be notified of such changes before the event.

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

CONDUCT AGREEMENT

I/we, the undersigned, understand that inappropriate behavior, including towards another student, adult leader, private party, church property, vehicles, or the property or persons of places we may visit during an event, I/we agree to reimburse all damages caused by the child. Should it be necessary for my child to return home due to medical or disciplinary reasons, the undersigned shall assume all transportation costs.

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

ACKNOWLEDGEMENT OF RISK AND RELEASE

I/we, the undersigned, acknowledge that I/we am/are aware of and have investigated to the extent necessary all dangers and risks associated with RStudents activities, and affirm that my/our minor is healthy and physically able to participate in these activities. I/we assume the risk of such activities and agree to indemnify and hold harmless Renaissance Church. I/we, the undersigned, also acknowledge that any RStudents activity may involve transportation in a personal vehicle, a van or a bus, and I/we assume the risks associated with such transportation and agree to indemnify and hold harmless Renaissance Church. I/we, the undersigned, also acknowledge and assume the risks of contracting and/or spreading contagious illness during RStudents activities, I/we agree to indemnify and hold harmless Renaissance Church, and I/we agree to follow all guidelines implemented by RStudents.

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

MEDICAL RELEASE

I/we, the undersigned, grant permission to RStudent servants/Renaissance Church members to assist with medical prescriptions if necessary and assist with any over the counter medicine that I/we have approved (ex. motrin). I/we will disclose any necessary medical information to ensure the well being of the participant(s), and I/we grant permission to RStudent servants/Renaissance Church members to make medical decisions on behalf of the participant(s) if faced with an emergency (ex. going to the hospital/necessary treatment).

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

MEDIA RELEASE

In connection with participation in any RStudents event/activity, I/we, the undersigned, hereby grant to Renaissance Church, its successors and those acting under its authority the right to use participant’s name, image and/or interviews in all forms of media including related promotion. I/we grant this right without compensation and release Renaissance Church, its successors and those acting under its authority from any claim that may arise regarding such use, including claims of defamation, invasion of privacy, or infringement of rights of publicity or copyright.

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

COMMUNICATION RELEASE

I/we, the undersigned, hereby grant permission for RStudents servants/Renaissance Church members in discipling relationships to communicate with the participant(s) listed above through the listed platforms: telephone, email, text message, GroupMe, Remind, and any other platform deemed as wise/beneficial communication. I/we acknowledge that the RStudents servants/Renaissance Church members will operate in wisdom and be above reproach as they communicate.

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

TRANSPORTATION RELEASE

I/we, the undersigned, hereby grant permission for RStudents servants/Renaissance Church members in discipling relationships to transport the participant(s) listed above. I acknowledge that I will be informed who will be transporting my child, when my child is being picked up/dropped off, the date, time, and location of the occasion. I/we acknowledge that the RStudents servants/Renaissance Church members will operate in wisdom and be above reproach while they provide transportation.

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

DISCIPLESHIP RELEASE

I/we, the undersigned, hereby grant permission for the participant listed above to participate in RStudents non-event discipleship with RStudents servants/Renaissance Church members. I/we acknowledge that this may be in small groups or one (1) to one (1) discipleship. I/we acknowledge that RStudents servants/Renaissance Church members will follow communication and transportation release protocols, as well as receiving permission from me, the parent/guardian, for a determined day. I/we acknowledge that the RStudents servant/Renaissance Church members will operate in wisdom and be above reproach with behavior, location, and content of the meeting.

YesNo

If no, please explain any concerns:*

Parent/Guardian Signature:*

Date:*

Date

Please verify that you are human:*

Medication

Dosage/Time