COKER STUDENT MINISTRIES

Student Information/Medical/Release Form Effective August 1, 2022- July 31, 2023

Please list and explain any health issues or chronic medical conditions (such as physical and/or psychological ailment, illness, limitations, disability, or condition to which your student is subject and of which the staff should be aware of, and what, if any action of protection is required on account thereof.)

has my/our consent in attending all Coker Student activities sponsored by Coker United Methodist Church beginning August 1, 2022 July 31, 2023. I/We have completed the contact information, the medical history information, and provided a copy of the insurance card. Effective immediately, I assume all risk and hazards and do hereby release and agree to hold harmless Coker United Methodist Church and its servants, volunteers, agents and employees from all liability for personal injury or property damage for all actions taken in good faith during church activities. Additionally, I hereby release and agree to hold harmless the church and its servants, volunteers, agents, and employees from all liability in the event that I contract COVID-19 virus during a church activity. In the event I cannot be reached or cannot communicate in an emergency, I hereby give my permission to the physician, hospital, or medical service selected by the leaders of the church to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child or myself as named above. It is understood that a conscientious effort will be made to communicate with me or the emergency contact listed before any action is taken. I accept responsibility for any and all expenses incurred from medical treatment provided. I have read this release and understand its term and execute it voluntarily and with full knowledge of its significance.

We understand that many young people use digital tools for communication Therefore, we are requesting your permission to stay in contact with your student via digital communication. Staff, Leaders, and Volunteers will be required to follow the Child/Youth Vulnerable Adults safety policy at all times. Select the boxes below to give permission for the particular form of communication.

I/We understand Coker UMC from time to time produces material about its programs. I understand that my student named on this form may be included in videos or photographs taken by church or church activities. I hereby give my consent for photographs and/or videos to be taken of my student to be used for church publicity on website, Facebook, or other social media.

Coker United Methodist Church I Family Ministries I 231 E. North Loop Rd., San Antonio, TX 78216 I 210.494. 3455