2025 Youth Medical release

Medical Release & Permission Form

Effective dates: January 2025 to December 2025

For your information, we expect each student to conform to these rules of conduct:
-No possession or use of alcohol, drugs, tobacco (including vapes)
-No offensive language
-No fighting, weapons, fireworks, lighters, or explosives
-No offensive or immodest clothing
-No boys in girls' sleeping quarters and no girls in boys' sleeping quarters
-Participation with the group is expected
-Respect property
-Respect one another, staff, and adult leaders
-Respect and comply with event schedules.

Students who fail to comply with these expectations may be sent home at their parents' expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct.

Student Signature

Date

Activities may include, but are not limited to: sledding, paintball, Airsoft, cookouts, boating, water skiing, swimming, basketball, roller skating, Little Corona cliff diving, games in the park/on campus, soccer, broom ball, ice skating, volleyball, softball, baseball, camping, snowboarding, hiking, biking, concerts, bible studies, golfing, miniature golfing, scavenger hunts throughout town, hayrides, river rafting, repelling, boulder hopping, target practice, archery, air soft games, ATV riding, fire building, mission trips, and skate parks. Note: If you desire to limit your child's participation in any event, please submit your wishes in writing to the Calvary Chapel Old Towne Office prior to the event.

_______________________________ has my permission to attend all youth activities sponsored by Calvary Chapel Old Towne from January 1, 2025 through December 31, 2025.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff and volunteer leaders 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 Calvary Chapel Old Towne. I/we understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the church, its staff, agents, pastors, 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 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 about is accurate at the 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 expense should they become ill or if deemed necessary by the student ministries staff member.

Parentguardian signature

Date

Student Last Name

Student First name

Student Middle Name

Student Age

Student Birthday

Year in school

Sex

MaleFemale

Parent Email

example@example.com

Address

Street Address

Street Address Line 2

CityState

Zip

Student Phone Number

Medical Insurance Company

Policy # (if known)

Mother's Name

Mother's Home Phone Number

Mother's Work Phone Number

Father's name

Father's Home Phone Number

Father's Work Phone Number

Emergency contact (Other than Parent)

Emergency Contact Home Phone Number

Emergency Contact Work Number

Physician Name

Physician Office phone number

Dentist Name

Dentist Office phone Number

If necessary, describe in detail 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. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken. Check the following areas of concern for this student. If necessary, add another page with details: 1. For your child's safety and our knowledge, is your student good swimmerfair swimmernon-swimmer 2. Does your child have allergies to- pollens 3. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following: asthmaepilepsy / seizure disorder frequently upset stomachphysical handicap

1. For your child's safety and our knowledge, is your student a-

Good SwimmerFair SwimmerNon-swimmer

2. Does your child have allergies to:

pollensmedicationsfoodinsect bites

3. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:

4. Date of last tetanus shot (if Known)

Date

Additional comments

Does your child wear

GlassesContact Lenses

Please list and explain any major illnesses the child has experienced during the last year:

Should this childs activities be restricted for any reason Please explain

Calvary Chapel Old Towne Garrett Marin 714-290-5808

Medical History: