Student Ministry Medical History & Release Form 2025

Student Ministry Medical History & Release Form 2025
Participants Details
Participant's name:

First NameLast Name
Grade:
Date of Birth:

MonthDayYear
Date
Parent's email:
example@example.com
Parents Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Legal Guardian's Name:

First NameLast Name
Parent Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Insurance Co.
Policy No.
Family Physician:
Family Physician Phone:
Please enter a valid phone number.Format: (000) 000-0000.
If parent/guardian can't be reached in an emergency, please contact:
Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
The following information is required to ensure that your student's individual needs are met while attending Crossroads UMC. Information is confidential and will be made available only to staff, adult counselors, and medical professionals, i.e., those who are directly responsible for your child's well-being. In the event of an emergency, every effort will be made to contact the parents or designated individual. For their safety and well-being, no child will be allowed to attend without a completed and signed Student Ministry Medical History & Release Form 2025.
Date of student's last tetanus shot:

MonthDayYear
Date
Please list any physical conditions that the program staff and adult counselors should be aware of (sleepwalking, epilepsy, diabetes, fainting, depression, eating disorders, asthma, etc.). Please be specific so that we can provide the best care for your child.
Is your student allergic to any food, medication or insect bites?
If yes, please list particular allergy and probable reaction:
Is your student currently taking any medication?
If yes, please list all medications that your child will be bringing including complete instructions for administering:
May the staff/adult volunteer administer any of the following medications, simply check box to say yes, and uncheck box to indicate no:
Specific directions:
Does your child require a special diet:
Medical Release and Permission Paragraph
(Student's name) *has my permission to attend events with Crossroads UMC Student Ministry. I understand that the various events may involve physical activity, manual work, and recreational activities. I acknowledge that reasonable measures will be taken to safeguard the health and safety of all participants in case of a medical emergency. I hereby authorize calling a physician at my expense to provide whatever medical or surgical treatment is necessary. I understand that I will be notified as soon as possible in case of any emergency affecting my child.

I agree to indemnify and hold harmless Crossroads UMC, its officers, agents, volunteers and employees regarding any and all claims, damages, expenses or injuries arising out of any incident to my or my child's pariticipation in this project, unless such loss or injury results directly from the neglect or willful act of an officer, agent, volunteer or employee of Crossroads UMC acting within the scope of his/her employment.
Parent/Guardian's Name:
You have my permission to use photographs or videos in which my child appears for Crossroads UMC for sharing events with the congregation and publicity purposes. Parent/Guardian's Name:
Should be Empty:

Student Ministry Medical History & Release Form 2025

If parent/guardian can't be reached in an emergency, please contact:

Medical Release and Permission Paragraph