CPC Students Release Form 25-26

Medical & Image Release Form

A completed form is required for student participating in CPC Student Activities at, or hosted by, Community Presbyterian Church. This form will be kept on file for one (1) year as a medical and image release. If your contact, medical or insurance information changes, please contact the CPC Office or submit another online form to update your information. This release is valid June 1, 2025 to June 1, 2026.
Student's Name*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any allergies:
Medications or supplements taken regularly:
Medical information needed in case of emergency:
Parent / Guardian Name*

First NameLast Name
Cell Phone Number*
Work Phone Number
Parent / Guardian Name

First NameLast Name
Cell Phone Number
Work Phone Number
Emergency Contact (If parents/guardians cannot be contacted)*

First NameLast Name
Emergency Contact Phone Number*
Emergency Contact (If parents/guardians cannot be contacted)*

First NameLast Name
Emergency Contact Phone Number*
Medical Insurance (if applicable):
Policy Number (if applicable):
Group Number (if applicable):
Subscriber's Name (if applicable):
MEDICAL RELEASE:

I hereby give my permission, for myself or my child, to participate in an activity organized by Community Presbyterian Church Ventura. I hereby release, hold harmless and absolve Community Presbyterian Church Ventura, their pastors, leaders, staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be they individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Community Presbyterian Church Ventura staff or any adult leader acting on behalf of Community Presbyterian Church with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate} licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child's medical allergies, medications being taken, medical problems and other pertinent information.
Signature*

Clear
Parent / Guardian
Submitted Date*

MonthDayYear
Date
IMAGE RELEASE:

I agree that Community Presbyterian Church Ventura may tape or photograph my child and record his or her voice during their participation in the activity. I agree that Community Presbyterian Church Ventura will be able to use them, in whole or in part. whether In original or modified form in any manner or media, Including without limitation, for the purpose of advertising, promoting, and publishing Community Presbyterian Church Ventura whether doing the activity or thereafter. I hereby release and discharge Community Presbyterian Church Ventura and an affiliated entities from any and all claims, demands, or causes of action that I shall in connection with the use and exercise of the rights granted in this release. (When used in the public realm identifying information will be used responsibly e.g. names will not be attached to specific pictures or video images on the church's website, social media accounts, etc.)
I, (The Parent/Legal Guardian) give consent for my child's image releaseI, (The Parent/Legal Guardian) do not give consent for my child's image release
Signature*

Clear
Parent / Guardian
Submitted Date*

MonthDayYear
Date
Should be Empty:

Medical & Image Release Form