Youth Medical & Photo Release Form
Each student must fill out the information below completely. This form will be kept on file for one (1) year as a medical release. If your medical or insurance information changes, please contact the Student Ministry Office or submit another online form to update your information. Form is valid for the year of 2024-25
Student's Name
*
First Name
Last Name
Cell Phone Number
*
Gender
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
School
*
Grade
*
Please Select
6th
7th
8th
9th
10th
11th
12th
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List any Allergies or Medical Info your Child has:
List activities your Child is involved in:
Parent / Guardian Name
*
First Name
Last Name
Cell Phone Number
*
*
Parent / Guardian Name
First Name
Last Name
Cell Phone Number
*
Emergency Contact (If parents cannot be contacted)
*
First Name
Last Name
Emergency Contact Phone Number
*
Signature
*
Parent / Guardian
Submitted Date
*
-
Month
-
Day
Year
Date
Student Signature
*
Parent / Guardian
Submitted Date
*
-
Month
-
Day
Year
Date
Take Photo of the front of your insurance card
Take Photo of the back of your insurance card
Check the medicine that we may give to your child
*
Ways you can help, check mark the things you can help with
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