WHPC Medical and Photo Release

WESTLAKE HILLS

PRESBYTERIAN CHURCH | Valid till November 1, 2025 | Medical and Photo Release
Student #1 Information
Name

First NameLast Name
Gender
Date of Birth mm/dd/yyyy

MonthDayYear
Date
Email
example@example.com
Phone
Anticipated High School Graduation Year
Student #2 Information
Name

First NameLast Name
Gender
Date of Birth mm/dd/yyyy

MonthDayYear
Date
Email
example@example.com
Phone
Anticipated High School Graduation Year
Student #3 Information
Name

First NameLast Name
Gender
Date of Birth mm/dd/yyyy

MonthDayYear
Date
Email
example@example.com
Phone
Anticipated High School Graduation Year
Student #4 Information
Name

First NameLast Name
Gender
Date of Birth mm/dd/yyyy

MonthDayYear
Date
Email
example@example.com
Phone
Anticipated High School Graduation Year
Parent/Legal Guardian Information
Name
Email
example@example.com
Phone
Family Address (including city/state/zip)
Additional Parent/Legal Guardian Information
Name
Email
example@example.com
Phone
Other Emergency Contact Information
Name
Relationship to Student
Phone:
Medical Information
Insurance Company Name
Name of Insured
Policy/Group #
RxID/Group #
Please list and explain any major illnesses & surgeries the student experienced during the past year. If none, answer NA.
Student #1
Student #2
Student #3
Student #4
Medical History: Please list and explain any chronic medical conditions. If necessary, describe in detail the nature and severity of any physical and/or psychological condition of which the staff should be aware and what, if any, action of protection is required.
Student #1
Student #2
Student #3
Student #4
Please list medications, prescription and non-prescription, taken regularly. If none, answer NA.
Student #1
Student #2
Student #3
Student #4
Please list any known allergies (food, drug, environmental, etc.) If none, answer NA.
Student #1
Student #2
Student #3
Student #4
Please list any activity restrictions.
Student #1
Student #2
Student #3
Student #4
Date of last Tetanus (DTaP/DTP/DT/Td/Tdap) shot:
Student #1
Student #2
Student #3
Student #4
Physician Information
Name
Phone
Dentist Information
Name
Phone
Photo Release
I give permission for any videos or photographs taken of the above named student(s) to be used
Behavior Contract
I understand and agree that I have informed the student(s) named above of the behavior expectation listed below and he/she/they has/have agreed to abide by them. I understand and agree that if said student(s) fails to comply with these expectations, he/she/they will be sent home and I will incur all expenses related to transporting him/her/them home.
Student Behavior Expectations:
- No students can drive without proper authorization
- No possession or use of alcohol, drugs, tobacco or pornography
- No fighting, weapons, fireworks, lighters, explosives, etc.
- No offensive or immodest clothing
- No opposite genders in sleeping quarters
- Participating with the group is expected
- Respect property
- Respect one another, staff and adult leaders
- Respect and comply with event schedules
I agree
Parental Consent
Consent Form:

I, hereby grant permission for the student(s) named above to participate in all youth activities sponsored by Westlake Hills Presbyterian Church from November 1, 2023, to November 1, 2024.

This consent form authorizes the seeking of necessary medical attention for the student(s) and releases Westlake Hills Presbyterian Church (hereinafter “WHPC”) and its staff from any liability against personal losses of the named student(s).

I confirm that I have legal custody of the student(s) mentioned above and provide consent for their attendance at events organized by WHPC.

By signing below, I acknowledge the following:
- Activities may include participation in sporting/recreational events. (Note: If you wish to limit your student’s participation in any event, please submit your wishes in writing to the WHPC Youth Ministries Director(s) before the event.)
- I authorize transportation for the student(s) to and/or from church-sponsored events and meetings, including church-provided transportation or adult-driven transportation (WHPC Youth Staff, adult volunteers). Additionally, I understand that my student(s) may have one-on-one meetings with WHPC Staff or Volunteers.
- In the event of injury or need for medical/dental attention during a church-sponsored event, I authorize church representatives or event sponsors to secure necessary treatment for the student(s). I acknowledge responsibility for any medical costs not covered by insurance.
- I release WHPC, its staff, volunteers, agents, and governing bodies from liability for any personal injury, property damage, or wrongful death arising during or after the participation of the named student(s) in church-sponsored events between the specified dates.
- I accept full responsibility for the release of the student(s) to my custody and care if they are involved in activities violating or compromising WHPC rules, policies, or purposes. I understand that I am liable for any financial costs if the student(s) are sent home for disciplinary reasons.
- I confirm that all information provided is accurate and agree to the terms stated herein. This release is effective from November 1, 2023, through November 1, 2024, unless terminated in writing.
I agree
Electronic Signature (E-signature) Agreement: By entering your name, initials and the date of signature, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. By entering your name, initials and date of signature, you consent to be legally bound by the terms and conditions contained in this form.
Initials
Date of E signature

Clear
Should be Empty:

WESTLAKE HILLS

Student #1 Information

Student #2 Information

Student #3 Information

Student #4 Information

Parent/Legal Guardian Information

Additional Parent/Legal Guardian Information

Other Emergency Contact Information

Medical Information

Photo Release

Behavior Contract

Parental Consent