• Student Permission, Medical History, & Release Form

    We know... you hate them as much as we do. So thank you for taking the time to complete this form! Below you will fill out information giving us permission to have your student participate, as well as giving us some medical history and permission to treat if necessary. We rarely have to use these forms, but trust us... they are necessary, and occasionally need to be used.

  • Student Information

  • Emergency Contact

  • Parent/Guardian Information

  • Insurance Information

  • Health History

  • Has your student had any of the following?

  • Please indicate if your student has had any of the following diseases and give approximate dates:

  • Please indicate if your student has any of the following allergies and provide any important details we should know about:

  • Physician and Medical Care Provider Information

  • Activities and Restrictions

  • For your student's safety and our knowledge, is your student a:
  • Does your student wear:

  • Authorization of Treatment and Self-Indemnification

  • AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR

    I (we), the undersigned, parent(s) or legal guardian(s) of this participant (hereinafter “my child” or “student”), a minor, do hereby

    authorize First Christian Church’s staff and Student Ministry leaders as agent(s) for the undersigned to consent to an x-ray

    examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be

    rendered under the general or special supervise and/or surgeon licensed under the provisions of the Medicine Practice Act

    whether such diagnosis or treatment is rendered at the office of said physician or at a hospital. It is understood that this

    authorization is given in advance of specific diagnoses, treatment, or hospital care being required but is given to provide

    authority and power on the aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital

    care aforementioned physician in the exercise of his best judgment may deem advisable. If it should become necessary my

    child to receive medical treatment for any reason, I agree to submit all claims to my insurance company. I also accept full

    responsibility for the cost of medical treatment for any injury suffered while taking part in the activity, over and above that

    which is covered by my insurance.

     

     

    RELEASE OF LIABILITY AND SELF INDEMNIFICATION

    There is a potential risk when traveling and/or participating in any Student Ministry ministry group activity. I (we), undersigned parent(s)

    or legal guardian(s), do for myself and on behalf of my child participant do hereby release, forever discharge, and agree to hold

    harmless First Christian Church, its Student Ministry volunteers, or paid staff thereof from any and all liability, claims or

    demands for personal injury, sickness, or wrongful death, as well as property damages and expenses, of any nature whatsoever

    which may be incurred by the undersigned and/or the child participant that occur while said is participating in a church youth

    group or children’s ministry trip or activity. Furthermore, I and on behalf of my child hereby assume all risk of personal injury,

    sickness, death, damage, and expense as a result of participation. The undersigned further agrees that in the event any claim for

    personal injury, property damage, or wrongful death shall be prosecuted against First Christian Church, its volunteers, or paid

    staff, we hereby hold harmless and indemnify said organization(s), its volunteers, employees, and agents, for any liability

    sustained as the result of negligent, willful, or intentional acts of said persons otherwise, including expenses incurred attendant

    thereto.

     

    PERMISSION TO PARTICIPATE

    As the parent or legal guardian of my child, I hereby consent for my child to attend and participate in all activities provided by

    First Christian Church. Further, should it become necessary for my child to return home due medical reasons, disciplinary action

    or otherwise, I (we) hereby assume all transportation costs.

  • Signature*
  • Date*
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  • Date
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  • Should be Empty: