Valley View Students 2025 Medical Release Form

Student Ministry 2025 Medical Release Form
Student's Name*

First NameLast Name
Current Grade*
School Student Attends *
Student's Email*
example@example.com
Student's Cell Number*
Please enter a valid phone number.
Student's Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Insurance Company
Claims To Be Mailed To
Policy or ID Number
Family Physician
Phone Number
Please enter a valid phone number.
Medications Currently Taking (list all, even vitamins)
List Allergies
Date of Last Tetanus Shot

MonthDayYear
Date
Permission to Give

IbuprofenAcetaminophenAspirin
Special Instructions Regarding Student
My child: Student's Name Here may participate in all Valley View Baptist Church Student Ministry events and activities for the 2025 calendar year. As a parent or guardian, I authorize an adult counselor to make legal decisions, medical decisions, or otherwise concerning for said minor during the time of Valley View Baptist Church Student Ministry events. In the event that I can not be reached. I also agree that I will immediately notify Valley View Baptist Church Student Ministry, in writing, of any changes to the information above, medical or otherwise. I hereby release Valley View Baptist Church and its sponsors of any legal responsibilities and liability in the event of an accident or injury. As a parent or guardian, I have carefully and truthfully provided all the information requested and give my permission for my child to participate in Valley View Baptist Church Student Ministry events in 2025.My child and I understand that he/she will be expected to obey the rules, regulations and policies of Valley View Baptist Church Student Ministry events.

*I give permission for my child to be photographed and or videoed at any event, and for those photos to be used in promoting the student ministry of Valley View Baptist Church.
Parent/Guardian Signature*

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Date

MonthDayYear
Date
Student Signature*

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Date

MonthDayYear
Date
Should be Empty:

Student Ministry 2025 Medical Release Form