Celebration Church Student Health, Consent, and Release Form - 2023
Note To Parent/Guardian: Celebration Church Student Ministries wants all of our camps, missions trips, retreats, and events to be safe and healthy ones. However, in the event of an accident or illness, it is important that we have the following information.
Student Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
School
*
Birthday
*
-
Month
-
Day
Year
Date
Grade
*
6th
7th
8th
9th
10th
11th
12th
Student Cell Phone Number
*
-
Area Code
Phone Number
Parent Name(s)
*
Parent Cell Phone Number
*
-
Area Code
Phone Number
Parent E-mail
*
example@example.com
Parent Cell Phone Number
-
Area Code
Phone Number
Parent E-mail
example@example.com
Emergency Contact other than parent
*
First Name
Last Name
Relationship to Student
*
Emergency Contact Number
*
-
Area Code
Phone Number
2nd Emergency Contact other than parent
*
First Name
Last Name
Relationship to Student
*
Emergency Contact Number
*
-
Area Code
Phone Number
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Insurance Information
Health Insurance Company Name
*
Group Name
*
Policy Number
*
Insurance Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Care Physician
First Name
Last Name
PCP Phone Number
-
Area Code
Phone Number
Medical History
If none apply please write N/A in box
Allergies
*
Current Medication
*
Dietary Restrictions
*
Date of last Tetanus Immunization
*
Additional Health Information/Activities to be Limited
*
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Authorization For Treatment/Acknowledgement of Inherent Risk
I hereby give permission to the medical personnel selected by the staff of Celebration Church to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Celebration Church Student Ministries to secure or administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named above. I authorize the physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgment as to the requirements of such diagnosis or medical, dental or surgical treatment. I agree to remain fully liable and responsible for the payment of any such hospital, doctor, ambulance, dental or medical fees. I further agree that in giving this permission and authorization, Celebration Church does not assume any responsibility or liability for the payment of such hospital, doctor, ambulance, dental or other medical fees which may be incurred. The completed forms may be photocopied and maintained by authorized personnel. This form is valid by my permission through December 31, 2023.
Sign here if you have read and agree
*
Release of Liability
I acknowledge and understand there are inherent risks associated with many Celebration Church Student Ministries activities. I will assume the risk associated therewith, whether known or unknown to me at this time. I recognize that my student’s attendance at a Celebration Church sponsored event is a privilege and as a consideration for this privilege, I release Celebration Church, including its employees, agents and trustees, from responsibility for my student’s accidental physical injury, including death or illness while at a sponsored trip or activity or during travel to and from events. This release is intended to include all claims made by my family, estate, heirs, personal representatives or assigns.
Sign here if you have read and agree
*
Media Consent
I hereby grant permission to Celebration Church the right to take, use, reproduce, and/or distribute photographs, films, video, and sound recordings of my child, without compensation or approval rights, for use in materials created for purposes of promoting the activities of Celebration Church.
Parent Consent
*
I Grant Permission
I Do Not Grant Permission
Deposits as Binding
I understand that all deposits made for Celebration Church sponsored events are non-refundable and may or may not be refunded at the discretion of Celebration Church staff. I also understand and acknowledge that by paying a deposit I am making a reservation and committing to paying the total cost of the trip or event. In the event, I must cancel that reservation, or if my student does not live up to the required expectations laid forth for that trip, I will pay the remaining balance if Celebration Church is unable to recoup that loss.
Sign here if you have read and agree
*
Parent Covenant
Celebration Church leadership reserves the right to send any student home, at your personal expense, in the event that a serious behavioral incident does occur with your son or daughter on any trip or activity. The leadership team will assess the situation, make a decision, call the parent and give options to what action will then take place. Examples may include, but are not limited to, fighting, drug or alcohol use, sexual activity, vandalism, violent behavior, and disobedient behavior.
Sign here if you have read and agree
*
Minor Medical Care
During Celebration Church sponsored trips or activities, it’s always inevitable that students have minor health and first aid issues. I hereby give permission for Celebration Church and it’s agents to administer the following over-the-counter medication and/or first aid to my child (please check all that apply).
Medication Allowed
*
Advil (Ibuprofen)
Cough Medicine
Cold Medicine
Sunscreen
Tylenol
Tums
Cough Drops
Benadryl (allergy)
First Aid
Dramamine
Claritin (allergy)
Immodium (diarrhea)
Caladryl (itching)
Anti-Itch Cream
Sign here if you give permission to administer the above medications
*
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