COKER STUDENT MINISTRIES RELEASE FORM 2025-2026

COKER STUDENT MINISTRIES
Food/Medical Allergies
Student Name
Gender
Address

Address

Street Address Line 2

CityState

Zip Code
Student Cell Number
DOB
Grade
School Name
Parent/Legal Guardian's Name
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Parent/Legal Guardian's Name
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Relationship to Student
Cell Phone
Format: (000) 000-0000.
Is there any child custody information that we should be aware of? If so please list
Please list and explain any health issues or chronic medical conditions (such as physical and/or psychological ailment, illness, limitations, disability, or condition to which your student is subject and of which the staff should be aware of, and what, if any action of protection is required on account thereof.)
Please list them
Please list any medications taken regularly
Date of last Tetanus shot

MonthDayYear
Date
Student's Physician
Phone
Format: (000) 000-0000.
Consent To Treat And Release Of Liability

A copy of the front and back of the medical insurance card must be provided with this form.
Insurance Card Front and Back File Upload

Cancelof
Students Name
has my/our consent in attending all Coker Student activities sponsored by Coker Methodist Church beginning August 1, 2025 - July 31, 2026. I/We have completed the contact information, the medical history information, and provided a copy of the insurance card. Effective immediately, I assume all risk and hazards and do hereby release and agree to hold harmless Coker Methodist Church and its servants, volunteers, agents and employees from all liability for personal injury or property damage for all actions taken in good faith during church activities. In the event I cannot be reached or cannot communicate in an emergency, I hereby give my permission to the physician, hospital, or medical service selected by the leaders of the church to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child or myself as named above. It is understood that a conscientious effort will be made to communicate with me or the emergency contact listed before any action is taken. I accept responsibility for any and all expenses incurred from medical treatment provided. I have read this release and understand its term and execute it voluntarily and with full knowledge of its significance.
Print Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian
Date

MonthDayYear
Date
Communication/Photo/Media/Travel Release

Please Initial
We understand that many young people use digital tools for communication. Therefore, we are requesting your permission to stay in contact with your student via digital communication. Staff, Leaders, and Volunteers will be required to follow the Child/Youth Vulnerable Adults safety policy at all times. Select the boxes below to give permission for the particular form of communication.
Parent or Guardian Initials
Please Initial
I/We give permission for Coker to communicate with my student via (check all that apply)
I/We understand Coker from time to time produces material about its programs. I understand that my student named on this form may be included in videos or photographs taken by church or church activities. I hereby give my consent for photographs and/or videos to be taken of my student to be used for church publicity on website, Facebook, or other social media.
I/We give permission for any videos or photographs taken of the above name student to be used on Coker Facebook and/or other social media platforms.
Parent or Guardian Initials
I/We give permission for the above name student to be transported to and/or from church sponsored events and approved meetings by A) church provided transportation (car, van, buses, and planes) and/or B) adult driven (Coker Church, Coker Family Ministries, Coker Student staff and adult volunteers).
Parent or Guardian Initials
Print Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian
Date

MonthDayYear
Date
Coker Methodist Church I Student Ministries I 231 E. North Loop Rd., San Antonio, TX 78216 I 210.494.3455
Should be Empty:

COKER STUDENT MINISTRIES

Consent To Treat And Release Of Liability

Communication/Photo/Media/Travel Release