NEW ZION BAPTIST CHURCH
17387 New Zion Church Road Covington, LA 70435 985-892-4711
2026 Medical Release / Parent Consent/ and Code of Conduct
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Children's Ministry 1-6th grade
Youth Ministry 7th - 12th grade
Personal Information
Student's Name:
Age:
DOB:
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Month
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Day
Year
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Grade:
Gender:
Male
Female
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Cell Phone:
Medical Insurance Company:
Policy #
Mother's Name:
Phone #
Father's Name:
Phone #
Emergency Contact:
Phone #
Physician
Office #
Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, weakness, limitation, handicap, disability or condition to which your child is subject; and of which the staff should be aware. Also describe any action of protection that is required for that ailment, illness, weakness, limitation, handicap, disability, or condition. Submit this information below.
Check the following areas of concern for this student. If necessary, add another page with details:
1. For your child's safety, and our knowledge, is your child a:
good swimmer
fair swimmer
non-swimmer
2. Does your child have allergies to:
pollen
medications
food
insect bites
other
Please list allergies:
Please list food allergies:
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3. Does your child suffer from, or has ever experienced, or is being treated currently for the following:
asthma
epilepsy / seizure disorder
heart condition
diabetes
physical handicap
frequently upset stomach
4. Date of last Tetanus shot:
5. Does your child wear:
Glasses
Contact lens
6. Please list and explain any major illnesses your child has experienced during the last year:
7. Should your child's activities be restricted for any reason? If "yes", explain.
Additional Comments:
Electronic and Print Media
New Zion Baptist Church reserves the right to use both audio and video recording, along with still photography, at any church/youth event or activity. These images and recordings may be used in either electronic or print media. These images and recordings may also be used to promote the church children, or youth functions and events. These images and recordings may also be used for the propagation of the church's mission or ministry.
Transportation
I authorize New Zion Baptist Church to transport my student in a Church owned vehicle or personally owned vehicle, driven by an individual authorized by New Zion Baptist Church. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer.
Parental Consent
has my/our permission to attend all church/youth events and activities sponsored by New Zion Baptist Church (hereinafter the "church").
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 the child named herein.
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 activity or event, and I/we hereby release the church, its ministers, 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 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 medical
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care should the cost of that 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 mentioned above. I/We agree to notify the church, in writing, of any changes to the information provided herein. 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 student ministries staff member. I/We agree to allow the church to use any audio and video recording, along with still photography, featuring the student named above in a manner that the church deems beneficial for promotion or the church or propagation of the church's mission in or ministry.
Parent/guardian signature:
Date:
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Month
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NEW ZION BAPTIST CHURCH
17387 New Zion Church Road Covington, LA 70435 985-892-4711
2026 Rules of Conduct
We expect each youth/ child and leaders to conform to the following rules of conduct:
No possession or use of alcohol, drugs, tobacco or vape paraphernalia
No students can drive during church/youth activities without direct permission from parent/guardian
No fighting, knives (of any kind), weapons, firearms, fireworks, lighters or explosives
No offensive or immodest clothing
No boys in girls sleeping quarters and no girls in boys sleeping quarters
Participation with the group is expected at all times
Respect all property
Respect one another, staff and adult leaders. Bullying and exclusion of others will not be accepted.
Respect and comply with event schedules
Phones are strictly controlled during trips and other events
Students who fail to comply with these expectations may be/will be sent home from any church/children/youth event at their parent's expense. If there is reason to believe that items not allowed per these rules of conduct are in a student's bag or belongings, those items can/will be searched.
Student Agreement
I, have read the rules of conduct and permission to participate in church/youth events and activities. I agree to abide by the stated code of conduct.
Student signature:
Date:
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Month
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Day
Year
Date
Parental Agreement
has my/our permission to attend all church/youth events
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and activities sponsored by New Zion Baptist Church (hereinafter the "church"). I/We understand the rules of conduct expected of my/our child while attending activities of the church. I/We understand that if my child does not adhere to these stated rules, it will be my/our responsibility to pick them up or pay for his/her return home.
Parent/guardian signature:
Date:
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Month
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Day
Year
Date
NEW ZION BAPTIST CHURCH
17387 New Zion Church Road Covington, LA 70435 985-892-4711
Medicine Release
Name of Participant:
Prescription medications that should be given to my child. All medication should be labeled and turned in at check-in. Please include dosage and frequency:
In addition, permission is given for my child to use the following medications for minor injuries (yes/no) please include dosage.
Yes or no
Dosage (How Many?)
Tylenol (500 mg tablet) 6 hours apart:
Ibuprofen (200 mg tablet) 6 hours apart:
Pepto:
Benadryl (25 mg tablet)
Antidiarrheal (2 mg)
Topical Analgesic (biofreeze/bengay).
Neosporin
Hydrocortisone
Aloe(sunburns)
Allergies:
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Reaction:
Print Parent Name:
Parent Guardian Signature:
Date:
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Month
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Year
Date
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NEW ZION BAPTIST CHURCH