2019 WBC Youth Ministry Annual Medical Release & Permission Form

Youth Ministry Annual Medical Release & Permission Form

Wendell Baptist Church
Student's Information
Note: This form is good from the day it is completed until January 1, 2020.
Student's Full Name *

First Name Last Name
Student's Sex *
Student's Age *
Student's Birth Date *

Month Day Year
Year In School
Student's E-mail (if applicable)
(if applicable)
Student's Cell Phone Number (if applicable)

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Medical Insurance Company *
Medical Insurance Policy Number *
Insurance Card Photo (Front) *
Insurance Card Photo (Back) *
Primary Physician *

Prefix First Name Last Name
Primary Physician Office Phone *

- Area Code Phone Number
Dentist *

Prefix First Name Last Name
Dentist Office Phone *

- Area Code Phone Number

Parent's Information
Father's Name *

First Name Last Name
Father's Cell Phone *

- Area Code Phone Number
Father's Work Phone

- Area Code Phone Number
Mother's Name *

First Name Last Name
Mother's Cell Phone *

- Area Code Phone Number
Mother's Work Phone

- Area Code Phone Number
Alternative Emergency Contact
Alternative Contact's Name *

First Name Last Name
Alternative Contact's Cell Phone *

- Area Code Phone Number
Alternative Contact's Relation to Student *

Student's Agreement
For your information, we expect each student to conform to these rules of conduct…

- No possession or use of alcohol, drugs, or tobacco

- No students can drive

- No fighting, weapons, fireworks, lighters, or explosives

- No offensive or immodest clothing Participation with the group is expected

- No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters

- Respect property

- Respect one another, staff, and adult leaders

- Respect and comply with event schedules and rules

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 above 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's Signature *

Clear
NOTE: BY ACKNOWLEDGING AND SIGNING ABOVE, I, THE STUDENT, AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Today's Date

- Month - Day Year
Parental Permission
My son/daughter, has my permission to attend all youth activities sponsored by Wendell Baptist Church from this day through 01/01/2020.

Notes:

- Activities may include, but are not limited to the following: cookouts, boating, water skiing, swimming, ice skating, volleyball, softball, baseball, camping, skiing, snowboarding, hiking, concerts, Bible studies, miniature golf, student conferences, rock climbing, lock-ins, mission trips, service projects, small group trips, sleep-overs, and more.

- If you desire to limit your child’s participation in any event, please submit your wishes, in writing, to Gary Ring prior to that event.

- If your child fails to adhere to the above Student Agreement and needs to be sent home it will be at your expense.
Parent's Signature *

Clear
NOTE: BY ACKNOWLEDGING AND SIGNING ABOVE, I, THE PARENT, AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Today's Date

- Month - Day Year

Medical Release
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Wendell Baptist Church and its staff of any liability against personal losses of named child.

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 Wendell Baptist Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release Wendell Baptist 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 Wendell Baptist 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 student ministries staff member.
Picture Release and Authorization
I/we give Wendell Baptist Church the absolute right and permission to use my/our child's photograph(s) in promotional materials and publicity efforts. I understand that the photographys may be used in publication, print ads, electronic media (e.g. video, internet, etc.), or other form of promotion. I/we release Wendell Baptist Church from liability for any violation of any personal right I/we may have in connection with such use. I/we understand that my/our child's name and/or address will not be published in any form.
Signature *

Clear
NOTE: BY ACKNOWLEDGING AND SIGNING ABOVE, I, THE PARENT, AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Today's Date

- Month - Day Year
Should be Empty:

Youth Ministry Annual Medical Release & Permission Form

Student's Information

Student's Medical History

Parent's Information

Alternative Emergency Contact

Student's Agreement

Parental Permission

Medical Release

Picture Release and Authorization