Student Ministry Parental Consent Form

The following form must be completed and signed by a parent or guardian.

STUDENT 1 Name

First NameLast Name

Date of Birth

Grade for 2025-2026 School Year

STUDENT Phone Number

Leave blank if student does NOT have a phone number.Format: (000) 000-0000.

STUDENT Email Address

Leave blank if student does NOT have an email address.

Does your child have any known allergies?

List Allergen and Reaction:

Is your child being treated for an injury or sickness or taking any form of medication for any reason?

Please Explain:

Does your child require a special diet?

Please Explain:

Does your child have or has your child ever had the following?

If Any Apply, Please Explain:

Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?

Please Explain:

Can your child swim?

Do you have another preteen or student to add?

STUDENT 2 Name

First NameLast Name

Date of Birth

Grade for 2024-2025 School Year

STUDENT Phone Number

Leave blank if student does NOT have a phone number.Format: (000) 000-0000.

STUDENT Email Address

Leave blank if student does NOT have an email address.

Does your child have any known allergies?

List Allergen and Reaction:

Is your child being treated for an injury or sickness or taking any form of medication for any reason?

Please Explain:

Does your child require a special diet?

Please Explain:

Does your child have or has your child ever had the following?

If Any Apply, Please Explain:

Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?

Please Explain:

Can your child swim?

Do you have another preteen or student to add?

STUDENT 3 Name

First NameLast Name

Date of Birth

Grade for 2024-2025 School Year

STUDENT Phone Number

Leave blank if student does NOT have a phone number.Format: (000) 000-0000.

STUDENT Email Address

Leave blank if student does NOT have an email address.

Does your child have any known allergies?

List Allergen and Reaction:

Is your child being treated for an injury or sickness or taking any form of medication for any reason?

Please Explain:

Does your child require a special diet?

Please Explain:

Does your child have or has your child ever had the following?

If Any Apply, Please Explain:

Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?

Please Explain:

Can your child swim?

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name 1

First NameLast Name

Parent 1 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent 1 Email

example@example.com

Parent/Guardian Name 2

First NameLast Name

Parent 2 Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent 2 Email

example@example.com

Emergency Contact

First NameLast Name

Relationship

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Student's Doctor

Student's Doctor's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Health Insurance Company

Insurance Group Number / Policy Number

MEDICAL TREATMENT AUTHORIZATION: I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I give consent to medical and surgical treatment as needed in the judgement of the treating physician chosen by representatives of Cottage Hill Baptist Church or one of its campuses. I also give consent to Cottage Hill Baptist Church or one of its campuses and its representatives permission to transport my child at their discretion in case of an emergency. I agree to notify the church in the event of any health changes which would restrict my child’s participating in any normal church activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.

CONSENT FOR PHOTOGRAPHY AND VIDEOS: I understand and allow photos and videos of my child to be taken while participating in events at Cottage Hill Baptist Church or one of its campuses and to be used in any publications. I also understand that publication of these photographs may be accomplished electronically via the Internet/World Wide Web and that after publication the church will be unable to prevent persons from gaining access to the Internet/World Wide Web, copying my child’s photographs and videos from there, and subsequently using, altering, or republishing them without my consent. I waive any claim for damages against Cottage Hill Baptist Church form unconsented use, altercation, or republication of my child’s photographs and videos by third parties accessing the Internet/World Wide Web.

CONSENT AND CERTIFICATION: I, the undersigned, being the parent or legal guardian of the child named above (the “student”), do hereby consent to the participation of my child/children in all of the regularly scheduled activities of Cottage Hill Baptist Church, Church of the Island, Downtown Church, or Bay Family Church, including transportation and any other activities customarily associated with church activities. Further, I certify that my child is physically fit and adequately trained to participate in such events (except as noted above).

Other Comments

My Name

First NameLast Name

Signature

Student Ministry Parental Consent Form

General Information

Family Information