Student Release and Permissions Agreement

Student Release and Permissions Agreement
Student Name *

First Name Last Name
Medical Release
Please list all history of medication allergies *
Transportation Release
Insurance Company/Policy # *
Personal Belongings Release
Discipline Release
Photo Release
General Release
Date *

Month Day Year
Date
I, being the legal parent/guardian of the participant give my permission for him/her to go, to travel,and to participate in any activity as mentioned above under the direction
of Community Covenant Student Ministries.
Signature

Clear
Printed Name:

First Name Last Name
Should be Empty: