COKER KIDS RELEASE FORM

Coker Kids Information/Medical/Release Form

Effective August 1, 2023- July 31, 2024
Food/Medical Allergies
Child's Full Name
Gender

MaleFemale
Goes by
DOB
Grade
School Name
Address

Address

Street Address Line 2

CityState

Zip Code
Parent/Legal Guardian's Name
Cell Phone
Email
example@example.com
Parent/Legal Guardian's Name
Cell Phone
Email
example@example.com
Emergency Contact
Relationship to child
Cell Phone
Is there any child custody information that we should be aware of? If so please list
Medical History
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 child is subject and of which the staff should be aware of, and what, if any action of protection is required on account thereof.)
Please list any
Please list any medications taken regularly
Date of last Tetanus shot

MonthDayYear
Date
Child's Physician
Phone
Consent To Treat And Release Of Liability

A copy of the front and back of the medical insurance card must be provided with this form.
Insurance Card Front and Back File Upload *

Cancelof
Childs Name
has my/our consent in attending all Coker Kids activities sponsored by Coker Methodist Church beginning August 1, 2023 July 31, 2024. 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 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. 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.
Print Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Photo/Media/Travel Released
I/We understand Coker from time to time produces material about its programs. I understand that my child 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 child to be used for church publicity on website, Facebook, or other social media.
I/We give permission for any videos or photographs taken of the above name child to be used on Coker Facebook and/or other social media platforms.
Parent or Guardian's Initial
Print Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
For 3rd - 5th Grade Only

Coker Extreme Kids Mission From The Heart
Families of 3rd - 5th graders interested in Coker Extreme Kids. You are not JUST a kid you can make a difference by helping childwill change the world! You are being called today to be part of Coker "Extreme" Kids. Mission From The Heart where your learn to serve our community. state, country, and sometimes even other countries! Grade 3rd. 5th begins in the fall.
I/We are signing our child up for Coker "Extreme" Kids and consent to his/her participating in local mission trips in the serve the community.
Parent or Guardian's Initial
I/We give permission for the above name student to be transported to and/or from church sponsored events approved meetings by A) church provided transportation (car, van, buses, and planes) and/or B) adult driven (Coker Church, Coker Family Ministries, Coker Student staff and adult volunteers). * All drivers have been DPS approved.
Parent or Guardian's Initial
Print Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Coker Methodist Church I Family Ministries I 231 E. North Loop Rd., San Antonio, TX 78216 I 210.494. 3455
Should be Empty:

Coker Kids Information/Medical/Release Form

Medical History

Consent To Treat And Release Of Liability

Photo/Media/Travel Released

For 3rd - 5th Grade Only