Medical-Ministry Release Form 2025

Medical/Ministry Release Form 2025

Student Name*

First NameLast Name

Date of Birth*

Date

Student Cell Phone

Address*

City*

State*

Grade*

Age*

Lives with:*

FatherMotherBothOther

Student Email Address

example@example.com

Mother's Name*

Mother's Email Address*

Mother's Cell Phone*

Father's Name*

Father's Email Address*

Father's Cell Phone

Emergency Contact Name (if mother or father cannot be reached):*

Phone*

If necessary, please 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 student may be subject and of which the staff should be aware, and what, if any action of protection is required on account thereof.

Does your student have allergies (check all that apply)?

Please Specify:

Course of treatment if exposed:

Does your student currently suffer, or ever experienced, any of the following (check all that apply)?

Detailed Description

Date of last Tetanus Shot

Does your student wear Glasses?

YesNo

Contact Lenses?

YesNo

Should your student's activities be restricted for any reason?

YesNo

Please explain:

4. Medications:

I authorize the disclosure of protected health information ("PHI") as defined under the privacy regulations pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") for the purpose of medical treatment for the student. GFCC, its employees, agents and volunteers cannot be responsible for the storage and administration of any and all prescription and/or over the counter medications that may be needed and necessary for the students. The parents and/or guardians acknowledge that they shall be solely responsible to make suitable arrangements for the student for his or her medications that shall not involve GFCC, its employees, agents or volunteers.

Front of Card

Back of Card

Family Physician

Phone

Family Dentist

Phone

Medical Insurance Company*

ID/Policy #*

Insurance Phone

Insurance Address

Policy Holder's Name*

Group #*

6. Articles of Consent:

In the event I cannot be reached to make arrangements for emergency medical attention, I consent to the provision of any emergency medical care deemed necessary for the health of my student including authorizing transport of my student to medical facilities. I understand that any and all medical and transport expenses incurred are my responsibility and that there is no medical insurance coverage provided by GFCC.
It is agreed that the student has been informed of and understands any potential hazards and liabilities of our various events. It is further agreed that the undersigned, his or her guardians and parents, heirs and assignees agree to refrain from holding GFCC; its employees and agents responsible for any injuries incurred while attending an event.
It is agreed that the student and parent and/or guardian have been informed of and understand any potential hazards and liabilities of our various events. I agree to release GFCC, its employees, agents and volunteers, from all liability for injury, death, property loss and damages that result from participation in our various activities on behalf of the student, including all liability that results from the negligence of GFCC, its employees, agents and volunteers.
I consent the use of any video image, photograph, audio recordings or any other visual or audio reproduction that may be taken of the participant during their involvement in any activity, event, or trip, to be used, distributed or shown as the church sees fit including but not exclusive to: slide shows, church website, social media or print media.

For your information, students are expected to abide by all event rules and guidelines including but not limited to the following:

No possession or use of alcohol, tobacco, or drugs.
No fighting, weapons, fireworks, lighters, or explosives of any kind.
No offensive or immodest clothing.
No boys in girl's sleeping quarters and vice versa at all times.
Participation for group activities is expected.
Respect each other's property; thievery and vandalism are not tolerated.
Respect peers, church staff, and adult volunteer leaders.
Respect and comply with event schedules and guidelines.

Students who fail to comply with these expectations may be sent home at the parent's

This release form will be kept on file for the remainder of the calendar year and cover all GFCC ministry events, trips and activities for this calendar year.

By signing you have agreed to the validity of all information provided and willfully agree to the above articles of consent as well as accepting all terms and guidelines set forth for the named student's participation.

Printed Name of Parent or Legal Guardian*

Signature of Parent or Legal Guardian*

Date*

Preferred Email Address: An email will be sent to you with a copy of this form, enter your preferred email. Thank you!*

example@example.com