Unity Students 2026-2027 Activities and Medical Release Form

Unity Students 26-27 Activities and Medical Release Form

Please complete all fields and provide the required parent/guardian signature.
Student Information
Last Name
First Name
Middle Name
Street Address
City/County
State
ZIP Code
Birthday

MonthDayYear
Date
Medical Information
Is the student currently taking any medicine or receiving any treatment?
If yes, please explain
Date of last Tetanus Toxoid Immunization — Month
Date of last Tetanus Toxoid Immunization — Year
Sinus Trouble
Asthma
Hay Fever
Heart Trouble
Epilepsy
Diabetes
Allergies — Food
Allergies — Medications
Allergies — Environmental
Other Medical Needs or Special Considerations, Explain
Physician and Insurance Information
Family Physician Name
Family Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Family Physician Address
Insurance Company
Insurance Policy Number
Please Upload FRONT & BACK of CURRENT INSURANCE CARD

Cancelof
Parent/Guardian Liability Release and Parental Consent

INITIAL ALL BELOW
Parent/Guardian Initials for Liability Release and Parental Consent - I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me or my child as a result of participation in Unity Student Ministry Activities from June 1, 2026 to August 31, 2027. This release is intended to discharge in advance Unity Baptist Church of Prince George, Virginia, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. Itis further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees. I give consent for my child, named above, to participate in the Unity Student Ministry of Unity Baptist Church, Prince George, Virginia activities and programs from June 1, 2026 to August 31, 2027, and I execute the above liability release on their behalf. - PLEASE INITIAL BELOW
Parent/Guardian Initials for Photo Release for Minor Children - I DO grant to Unity Baptist Church, its representatives and employees the right to take photographs of me, my property and my children in connection with the above-identified subject. I authorize Unity Baptist Church, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Unity Baptist Church may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. - PLEASE INITIAL BELOW
Consent for Treatment

I DO hereby give my consent to the church-appointed sponsor who is with my child or to any staff person, or their designee, who is present at the above-mentioned event(s) to have the above child treated by emergency medical personnel, a physician, a dentist or surgeon, in case of sudden illness or injury while participating in any church sponsored activities. It is understood that Unity Baptist Church of Prince George, Virginia will provide no medical insurance and/or payments for such treatment, and that the cost thereof will be at my expense.
If I DO NOT give consent, church authorities to take no action or to:
I have read and understood the foregoing registration liability release and parental consent form and agree to all of its terms and conditions as completed.
Printed Name of Parent/Guardian
Date

MonthDayYear
Date
Parent/Guardian Address
Parent/Guardian Phone #1
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Phone #2
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email #1
example@example.com
Parent/Guardian Email #2
example@example.com
Other Emergency Contact Person - Name
Other Emergency Contact Person - Phone #1
Please enter a valid phone number.Format: (000) 000-0000.
Other Emergency Contact Person - Phone #2
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Parent/Guardian
Should be Empty:

Unity Students 26-27 Activities and Medical Release Form

Student Information

Medical Information

Physician and Insurance Information

Parent/Guardian Liability Release and Parental Consent