2025 Cornerstone Church Medical Release & Permission Form

Today's Date*

Date

Child's Name*

First NameMiddle NameLast Name

Child's Birth Date*

Date

Child's Age

Year in School

Male/Female

Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Child's Primary Phone Number*

Please enter a valid phone number.

Child's Secondary Phone Number

Please enter a valid phone number.

Insured

First NameLast Name

Is Insured Billing address the same as student's address?

YesNo

Insured Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Medical Insurance Company*

Policy Number*

Physician

Physician Phone

Please enter a valid phone number.

Dentist

Dentist Phone

Please enter a valid phone number.

Father's Name

First NameLast Name

Father's Phone Number

Please enter a valid phone number.

Father's Email

example@example.com

Mother's Name

First NameLast Name

Mother's Phone Number

Please enter a valid phone number.

Mother's Email

example@example.com

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

Emergency Contact Relationship

1. For your child’s safety and our knowledge, is your child a*

Good SwimmerFair SwimmerNon-Swimmer

2. Does your child have allergies to*

Please list all known allergies

3. Please list all medications and dosages your child is currently taking

4. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following

If "Other" please describe below

5. Date of Last Tetanus shot

Date

6. Does your child wear

GlassesContact Lenses

7. Please list and explain any major illnesses the child experienced during the last year

Should this child’s activities be restricted for any reason? Please explain

Please have your student read and check that they agree to the following:*

No possession or use of alcohol, drugs, or tobaccoNo students may driveNo fighting, weapons, fireworks, lighters, or explosivesNo offensive or immodest clothingNo boys in girls’ sleeping quarters and no girls in boys’ sleeping quartersParticipation with the group is expectedRespect property, one another, staff, adult leaders, and comply with event schedules

I, {childsName}, have read the rules of conduct, the above evaluation of my health, and permission to participate in Cornerstone activities. I agree to abide by the stated personal limitations and code of conduct.

By signing this form, you agree to assume and accept all risks and hazards inherent in church-related travel, ministry, social and sport activities including transportation to and from activities. You also agree that you will not hold Cornerstone Church or its employees or volunteer assistants liable for damages, losses or injuries to the person named on this form. You understand that this form and your signature are for both medical and liability release and agree that {studentsName} has your permission to attend all activities sponsored by Cornerstone Church of Ione from January 1, 2025 to December 31, 2025.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. Signing this form indicates acknowledgement.

Photo and Video Release
I understand that the activities and events sponsored by Cornerstone Church of Ione are considered public and may be photographed, and that these photos may be presented in various church-sponsored media, including but not limited to: photos, videos, slide presentations, PowerPoint presentations, newsletters, bulletins and/or bulletin inserts, brochures, handbooks, programs, and Internet Web pages. I hereby remise, release and forever discharge Cornerstone Church of Ione from any liability for any injury or action against the above-named minor resulting from the use of such photos, video, or other image in any medium utilized. This release includes that Cornerstone Church of Ione will not be responsible for other users production, display, distribution, or modification of the minors images in any manner, nor will Cornerstone Church of Ione be responsible for defamation, misrepresentation, or criminal acts as a result of unauthorized use of Cornerstone Church of Ione images by third parties.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Children’s Ministries staff member or Lead Volunteer.

Signature of Mother or Legal Guardian

Signature of Father or Legal Guardian

2025 Cornerstone Church Medical Release & Permission Form

General Information

Insurance Information

Contact Information Information

Medical History

Code of Conduct

Release of Liability and Photo/Video Release