Medical Release/Release Form updated 2026

Medical Release & Permission Form

Please note that we expect all students to comply with these rules of conduct:

No possession or use of alcohol, drugs, or tobacco (including vapes)
No offensive language
No fighting, weapons, 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
Respect property
Respect one another, staff, and adult leaders
Respect and comply with event schedules.
Students who fail to comply with these expectations may be sent home at their parents' expense.

I, the student, have read the rules of conduct, the below evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct.

Student Signature*

Date*

Date

Activities may include, but are not limited to: sledding, paintball, cookouts, boating, water skiing, swimming, basketball, roller skating, Little Corona cliff diving, games in the park/on campus, soccer, broom ball, ice skating, volleyball, softball, baseball, camping, snowboarding, hiking, biking, concerts, bible studies, golfing, miniature golfing, scavenger hunts throughout town, hayrides, river rafting, repelling, boulder hopping, target practice, archery, air soft games, ATV riding, fire building, mission trips, and skate parks. Note: If you desire to limit your student's participation in any event, please submit your wishes in writing to the CCOT Office prior to the event.

To be filled out by the parent:

Students name*

Please print students name

has my permission to attend all youth activities sponsored by Calvary Chapel Old Towne from January 1, 2026, through December 31, 2026.

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff and volunteer leaders of any liability against personal losses of the named student. 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 Calvary Chapel Old Towne. I/we understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the church, its staff, agents, pastors, 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 student'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 if the health insurance provider does not reimburse it. Further, I/We affirm that the health insurance information provided is accurate as of the date signed below 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 student home at my/our expense should they become ill or if deemed necessary by the student's ministry leader.

Parentguardian signature*

Date*

Date

Medical Release & Permission Form

Effective dates: January 2026 to December 2026

Please fill out your student's information below:

Last Name:*

First & Middle Names:*

Age:*

MaleFemale

Birthday:*

Year in School:*

Student's Email:*

Address*

Street Address

Street Address Line 2

CityState

Zip

Home Phone:

Student's Cell Phone:

Medical Insurance Company:*

Policy #:*

Mothers name:*

Phone Number:*

Work Number:

Fathers name:*

Phone Number:*

Work Number:

Emergency contact:*

Phone number:*

Work Number:

Physician:*

Office phone:*

Dentist:*

Office phone:*

Check the following areas of concern for this student. If necessary, add more details below:

Good SwimmerFair SwimmerNon-Swimmer

4 Date of last tetanus shot*

MonthDayYear

GlassesContact LensesNone

6. Please list and explain any major illnesses the student experienced during the last year:

Should this student's activities be restricted for any reason? Please explain:

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any, action of protection is required on account thereof. Submit any information that is necessary below. Include names of medications and dosages that must be taken.