FC STUDENT RELEASE FORM

FC Student Release Form
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PARENT/GUARDIAN INFORMATION:
Guardian 1 Name First and Last*

First NameLast Name
Guardian 1 Relationship*
Guardian 1 Cell Phone Number*

Area CodePhone Number
Guardian 1 Email*
Guardian 2 Name First and Last *

First NameLast Name
Guardian 2 Relationship*
Guardian 2 Cell Phone Number*

Area CodePhone Number
Guardian 2 Email*
example@example.com
EMERGENCY CONTACT (OTHER THAN PARENT)
Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact Relationship*
MEDICAL INFORMATION
Physician Name*

First NameLast Name
Physician's Phone Number*

Area CodePhone Number
Medical Insurance Company*
Policy/Group ID #*
Medical Concerns/Allergies*
Liability Release
I, the undersigned, do hereby release, forever discharge and agree to hold harmless Family Church, its staff and those adults supervising any FC Student Ministry trip or event, thereof, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the student participant that occur while said student is participating in any FC Student Ministry trip or event.

Furthermore, I (and on behalf of my minor student participant) hereby assume all risk of personal injury, sickness, death damage and expense as a result of participation in any FC Student Ministry trip or event involved therein.

Medical Treatment Permission
I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency medical treatment or care deemed necessary by a licensed medical professional. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned student pursuant to the authorization granted above.

Transportation Permission
The undersigned does hereby give permission for my student to ride in any vehicle designated by Family Church staff or those adults supervising any FC Student Ministry trip or event. My student and I understand that SEATBELTS SHALL BE WORN AT ALL TIMES during transportation. Choice of Law, Jurisdiction and Venue: This Release shall be governed by, construed and enforced in accordance with the laws of the State of Florida, notwithstanding any choice of law rule. The parties agree any dispute that arises related to this Release (including but not limited to actions, suits, or judicial proceedings upon any claim) shall be instituted and maintained in St. Johns County, Florida. If it is judicially determined that either party may file an action, suit or judicial proceeding in federal court, such action, suit or judicial proceeding shall be in the Federal District Court for the Middle District of Florida.

RULES & GUIDELINES
All rules and guidelines are zero tolerance. If disobedience occurs parents/guardian may be contacted at the discretion of a Family Church Staff Member. If contacted, parents may be required to arrange for transportation and/or be responsible for any costs incurred.
POLICIES ACCEPTANCE By checking this box and, I am acknowledging that I have read each paragraph above and my e-initials constitutes my signature and approval of this document. I recognize that the thoughts and views expressed by Family Church and its representatives do not reflect that of St. John’s, Duval, Clay, Putnam and Flagler County Schools.*

I Agree
*I agree to all above noted releases, permissions and rules with regards to the Family Church Student Ministries. **

I Agree
Student E-Signature*
Parent/Guardian E-Signature*
Todays Date*

MonthDayYear
Date
Should be Empty:

FC Student Release Form

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

EMERGENCY CONTACT (OTHER THAN PARENT)

MEDICAL INFORMATION