Ignite Student Ministry

Ignite Student Ministry
Student Information
Name

First NameLast Name
School
Grade level 2024/25
DOB
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Food Allergies
I am interested in...
Parent/Guardian Information
Name

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

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Alternate Emergency Contact
Student Medical Information
Students regular physician
Phone Number
Please enter a valid phone number.
Please List any medical conditions of the student (asthma, diabetes, epilepsy, etc)
Please List any allergies of the student (food or medication)
Please List any current medications student is taking
Any other pertinent medical information
Insurance information
Company
Preferred Hospital
Plan number
Employee ID
FORMS
Authorization for Medical Treatment
Student name

First NameLast Name
I, the parent/guardian of the above listed child, understand that in the case of illness or injury to my child, (listed above), Ignite Student Ministry will try to notify me or the person I have listed above as an emergency contact. In case of medical emergency concerning my child, at a time when I or my listed emergency contact cannot be notified, I grant full power to the Ministry to

1) arrange for the transportation of my child, whether by ambulance or otherwise, to a proper facility where emergency medical treatment would normally be administered, including but not limited to, an emergency room of a hospital, a doctor’s office, or a medical clinic; and

2) sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of medical authorities at the facility. I give permission for Ignite Student Ministry staff and volunteers to provide routine first-aid and seek emergency medical treatment for my above named child.
Signature

Clear
Publicity Form
On occasion, Ignite Student Ministry and their affiliated churches take photographs or make an audio or video recording of children and/or adults involved in ministry activities. Such photographs or video records may be used by staff and participants to remember the activities or participants. In addition, such photographs and audio/visual recordings may be used in Minitsty and affiliated church publications or advertising materials to let others know about the Ministry. Also, local news organizations may learn about the activities or events, and the Ministry may invite or allow them to photograph or record such events to be used, distributed, or displayed as the agents of the Ministry sees fit.

I hereby expressly grant to the parish named above and/or the Diocese of Peoria the right, privilege and license to use the picture or likeness of my child/children in any photograph, movie, video production or any other forms of media publication and to use the verbal or written statements or declarations of my child/children for the purpose of publicizing, fostering and promoting the parish and its programs, or for any other purpose in furtherance of the mission of the parish and/or the Diocese of Peoria.
Signature

Clear
Liability Form
We (I), the undersigned, do hereby release, forever discharge and agree to hold harmless and defend Ignite Student Ministry, their affiliated churches, and the Diocese of Peoria, its directors, employees, and volunteers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, and loss or damage, of any nature whatsoever which may be incurred by the undersigned or the Participant while involved in the youth activities.

We (I) the parent(s) or legal guardian(s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry activities. Furthermore, we (I) [and on behalf of our (my) minor Participant(s)] hereby
assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in activities involved therein.

By signing below, I affirm that I have read and agree to the Publicity Waiver, and Liability Waiver in full.
Name of Student

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Ignite Student Ministry

Student Information

Parent/Guardian Information

Student Medical Information

Insurance information

FORMS

Authorization for Medical Treatment

Publicity Form

Liability Form