2024 Spring Creek Youth Ministry Medical Release and Permission Form

Spring Creek Church of Christ
Youth Ministry Student Release
and Permission Forms
All 8 sections of this form are valid from Parent/Guardian Signature Date (in section 6 of 8) through 12/31/2024
Student Information

Section 1 of 8
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
School*
Grade*
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's Phone*

Area CodePhone Number
Student's Email*
example@example.com
Adult Contacts

Section 2 of 8
Father/Guardian's Name*

First NameLast Name
Father/Guardian's Phone*

Area CodePhone Number
Mother/Guardian's Name*

First NameLast Name
Mother/Guardian's Phone*

Area CodePhone Number
Emergency Contact (other than those listed above)*

First NameLast Name
Relationship to Student*
Emergency Contact's Phone*

Area CodePhone Number
Medical Contacts

Section 3 of 8
Medical Insurance Company*
Medical Insurance Policy #*
Primary Care Physician Name*
Primary Care Physician's Phone*
Dental Insurance Company (if different)*
Dental Insurance Policy #*
Dentist Name*
Dentist's Phone*
Medical History

Section 4 of 8
Describe in detail below the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what if any action of protection is required on account thereof. *
Include names of medications and dosages that must be taken and list medications causing allergic reactions.*
Check the following 6 areas of concern for this student. If necessary, add more details about the following items below:*
1. Choose one that best describes your child:*

Good SwimmerFair SwimmerNon-Swimmer
2. Check all items your child is allergic to and add any important details above:*

PollensMedicationsFoodsInsect BitesNoneOther
3. Check all items your child currently suffers from or has ever suffered from:*

AsthmaEpilepsy / Seizure DisorderHeart TroubleDiabetesFrequently Upset StomachPhysical HandicapNoneOther
4. Date of last tetanus shot:*

MonthDayYear
Date
5. Check all items your child wears:*

GlassesContactsProstheticHearing AidsNoneOther
6. List and explain any major illnesses your child experienced during the last year. If your child's activities should be restricted for any reason, please explain fully:*
Student Expectations

Section 5 of 8
For your information, we expect each student to conform to these rules of conduct. Students who fail to comply with these expectations may be sent home at their parents' expense.Please check each item to signify your student has been made aware of each expectation:*

No possession or use of alcohol, drugs, tobacco, or vapeNo student can drive directly to an activity unless it is at the church buildingNo student can provide transportation from an activity except for a family member or a student who has been included in the Transportation Permission list in section 8 of 8.Students with a provisional license may not drive to or from activities during restricted hoursNo fighting, offensive language, or immodest clothingNo possession of weapons, fireworks, lighters, or explosivesNo person of the opposite sex in the same sleeping quartersParticipation in all scheduled activities of the group is expected unless medically restrictedRespect property, others people, and any reasonable requests of adult leaders
I, the student, have read and understand the rules of conduct and the above evaluation of my health, and seek permission to participate in the Spring Creek Church of Christ youth group activities. I agree to abide by the stated personal limitations and code of conduct.
Student's Signature*

Clear
Date*

MonthDayYear
Date
Permission & Release

Section 6 of 8
I, the student, have read and understand the rules of conduct and the above evaluation of my health, and seek permission to participate in the Spring Creek Church of Christ youth group activities. I agree to abide by the stated personal limitations and code of conduct.
Student's Name*

First NameLast Name
The student listed above has my permission to attend all youth activities sponsored by Spring Creek Church of Christ (hereinafter the “Church”)
Effective dates: Parent/Guardian Signature Date below through 12/31/2024
This consent form gives permission to seek whatever medical attention is deemed necessary and releases the Church and its staff of any liability against personal losses of named child.
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its elders, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the youth minister.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Photo Permission

Section 7 of 8
Student's Name*

First NameLast Name
I hereby grant the Spring Creek Church of Christ permission to use my likeness and/or the likeness of my child listed above in a photograph, video, or other digital media (“photo”) in any and all its publications, including web-based publications, without payment or other consideration.
I understand and agree that all photos will become the property of the Spring Creek Church of Christ and will not be returned.
I hereby irrevocably authorize the Spring Creek Church of Christ to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo.
I hereby hold harmless, release, and forever discharge the Spring Creek Church of Christ from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.
I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT:
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Transportation Permission

Section 8 of 8
Student's Name*

First NameLast Name
I give my permission to the following persons to transport my child, listed above, to and from Spring Creek Church of Christ youth events as described in section 6 of 8 in this document:
Authorized Driver's Name*

First NameLast Name
Authorized Driver's Name*

First NameLast Name
Authorized Driver's Name*

First NameLast Name
Authorized Driver's Name*

First NameLast Name
Authorized Driver's Name*

First NameLast Name
If any changes need to be made to the above list those changes must be made in writing to the church office via a new original form being submitted.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Your Email
example@example.com
Should be Empty:

All 8 sections of this form are valid from Parent/Guardian Signature Date (in section 6 of 8) through 12/31/2024

Student Information

Adult Contacts

Medical Contacts

Medical History

Student Expectations

Permission & Release

Photo Permission

Transportation Permission