Student Medical/Media Release

Student Medical/Media Release

This form will be held by the church until the student's 18th birthday.
Student Details:
Full Name*

First NameLast Name
Grade*
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Gender*

MaleFemale
Birthdate*

MonthDayYear
Date
Does the student have any Medical Condition(s) or Allergies that our staff should be aware of?*

NoYes
If you answered yes to the above question, please explain below.

Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Name

First NameLast Name
Address (Leave blank if same as student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address (Leave blank if same as student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Email
example@example.com

Medical/Media Release
I, Parent/Guardian Name* , the undersigned, am the parent/have legal custody of Student Name* (“student”) and have given my consent for him/her to attend the activities of Journey Youth Ministry (JYM). I understand that my student’s participation is purely voluntary, a privilege, and not a right and that my student elects to participate in the ministry activities. I agree to instruct my student to cooperate with the ministry team members in charge of the ministry activities.

I understand that all reasonable safety precautions will be taken at all times by the JYM team during events and activities but that there is the possibility of unforeseen hazards and a possibility of risk in any ministry or athletic event. Therefore, in the event of injury or illness occurring to my student while participating in the activities of the JYM, and related travel, the following will apply:
a.   Contact and Consent to Treatment Every attempt will be made by the JYM team to immediately contact the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give authorization to the JYM team leaders to give consent and authorizations for emergency medical care for my student by paramedics, physicians, nurses, or hospitals for necessary medications, medical treatments, and diagnostic or surgical procedures deemed necessary for the best interest of my student.
b.   Insurance Coverage Primary; Other Costs My insurance coverage for my student will be the primary and sole coverage in the event of a medical emergency and I will be responsible for payment of any costs that are not covered by my insurance. The insurance of the Church will not be secondary insurance nor shall the funds of the Church be used for unreimbursed expenses related to the emergency care.
c.   Release and Hold Harmless I hereby release and hold harmless the Church, its pastors, officers, employees, agents, and volunteers from any and all liability, claims, judgments, cost, and expenses, including attorneys’ fees, arising out of or related to the need or provision of emergency care for any injury or illness incurred or caused by my student, while participating in or traveling to or from the JYM activities.
Posting of Images, Photos, Video Clips, Voice Clips by Church on Church Media  Church, from time to time takes photos, videos, images, and voice clips of Students participating in Church activities and would like to post the images/sound on the Church Facebook, webpage, other social media, bulletin boards, and print media. The Church will never provide identification of Student other than the Student’s first name in a posting. Church will not provide the Student’s last name, date of birth, address, phone number or any other personal identification information in any posting.
By typing my name I am authorizing it as my signature*

First NameLast Name
Todays Date*

MonthDayYear
Date
Should be Empty:

Student Medical/Media Release

Parent/Guardian Information

Medical/Media Release