Plymouth Covenant Church Student Ministry Annual (2024-25) Medical Release and Permission Form

Plymouth Covenant Church Student Ministry Annual Medical Release and Permission Form

June 2024 to August 2025 - All Student Ministry Events
Student Name*

First NameMiddle NameLast Name
Birthday*

MonthDayYear
Date
Grade during the 2024-25 School Year:*

6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeOther
Gender (Biological gender at birth- this is how we house for overnight events)*

MALEFEMALE
School during 2024-25 School Year:*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Phone - ONLY INCLUDE IF STUDENT HAS A CELL

Area CodePhone Number
Student Email - ONLY INCLUDE IF STUDENT HAS AN EMAIL
example@example.com
If student is a visitor/guest what PCC student invited them?
(This will help us with housing/transportation to keep friends with those who invited them!)
Parent Name:*

First NameLast Name
Parent Cell Phone:*

Area CodePhone Number
Parent Email:*
example@example.com
Parent Name:

First NameLast Name
Parent Cell Phone:

Area CodePhone Number
Parent Email:
example@example.com
Preferred Email for communications:*
If parents cannot be reached in an emergency, alternate contact and relationship to student:*
Name and Relationship to student
Alternate Contact Phone Number:*

Area CodePhone Number
Student Medical History
List any allergies that your student has:*
Please list any other medical conditions or diagnosis that we should be aware of:*
Medications currently taking (please list name and dose):
Any restriction for student?

YesNo
If yes, please explain:
Medical Insurance Company:*
Medical Insurance Phone Number:*

Area CodePhone Number
Policy #:*
Physician:*
Physician Office Phone Number:*

Area CodePhone Number
Code of Conduct
For your information, we expect each student to conform to these standards of conduct:
- No possession or use of alcohol, drugs, or tobacco.
- No students can drive other students without parental consent either verbal or written (adult leader confirmed).
- No fighting, weapons, fireworks or explosives.
- No offensive or immodest clothing (can be seen up, down or through or underwear overtly visible).
- No boys in girls' sleeping quarters and no girls in boys' sleeping quarters.
- No electronic devices except cell phones if parents require (not for casual use or text messaging).
- Participation with the group is expected.
- Respect property.
- Respect one another, staff members, and adult leaders (verbally and physically).
- Respect and comply with event schedules.
Students who fail to comply with these expectations may be sent home at their parents' expense.

I, the parent(s) have read the rules of conduct and the above evaluation of my student's health. I/we hereby authorize my son/daughter to participate fully in all events sponsored by the Student Ministries at Plymouth Covenant Church during the dates listed above. In the event that medical treatment is required, I/we give permission to the group leaders, counselors, and/or qualified medical personnel to make a decision regarding treatment for illness, injury or emergency care for my child.

I/we agree that I/we am/are solely responsible for all medical costs associated with any accident or injury involving my child during events and travel to and from events. I/we agree that neither the Evangelical Covenant Church, The Northwest Conference, nor Plymouth Covenant Church, nor any agents, volunteers and/or employees associated with events will be held liable on account of my child. I/we also authorize Plymouth Covenant Church to utilize pictures and video taken of my child for promotional purposes, including posting event pictures to PCC's website or PCC's social media groups.
Parent Signature*
Date

MonthDayYear
Date
Some events will require separate registration forms to be filled out. The Standards of Conduct are in place to make PCC the safest possible place for all students to come, belong, get equipped and be sent out for ministry.

Activities may include, but are not limited to: all-nighters, overnighters, small group outings, service projects, cookouts, boating, water skiing, basketball, roller-skating, rollerblading, soccer, broomball, volleyball, softball, baseball, frisbee, hiking, biking, concerts, Bible Studies, miniature golf, hayrides, guys/girls night out, etc.
Note: If you desire to limit your student's participation in any event, please write them out below:
Should be Empty:

Plymouth Covenant Church Student Ministry Annual Medical Release and Permission Form

Student Medical History

Code of Conduct