Student Ministry Parental Consent Form
2025
The following form must be completed and signed by a parent or guardian.
General Information
STUDENT 1 Name
*
First Name
Last Name
Date of Birth
*
Grade for 2024-2025 School Year
*
STUDENT Phone Number
Leave blank if student does NOT have a phone number.
STUDENT Email Address
Leave blank if student does NOT have an email address.
Does your child have any known allergies?
*
Yes
No
List Allergen and Reaction:
Is your child being treated for an injury or sickness or taking any form of medication for any reason?
*
Yes
No
Please Explain:
Does your child require a special diet?
*
Yes
No
Please Explain:
Does your child have or has your child ever had the following?
*
Seizure Disorders
Asthma
Heart Murmur
Diabetes
Hay Fever
Kidney Disease
Sleep Walking
None of the Above
Other
If Any Apply, Please Explain:
Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?
*
Yes
No
Please Explain:
Can your child swim?
*
Yes
No
Do you have another preteen or student to add?
*
Yes
No
STUDENT 2 Name
*
First Name
Last Name
Date of Birth
*
Grade for 2024-2025 School Year
*
STUDENT Phone Number
Leave blank if student does NOT have a phone number.
STUDENT Email Address
Leave blank if student does NOT have an email address.
Does your child have any known allergies?
*
Yes
No
List Allergen and Reaction:
Is your child being treated for an injury or sickness or taking any form of medication for any reason?
*
Yes
No
Please Explain:
Does your child require a special diet?
*
Yes
No
Please Explain:
Does your child have or has your child ever had the following?
*
Seizure Disorders
Asthma
Heart Murmur
Diabetes
Hay Fever
Kidney Disease
Sleep Walking
None of the Above
Other
If Any Apply, Please Explain:
Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?
*
Yes
No
Please Explain:
Can your child swim?
*
Yes
No
Do you have another preteen or student to add?
*
Yes
No
STUDENT 3 Name
*
First Name
Last Name
Date of Birth
*
Grade for 2024-2025 School Year
*
STUDENT Phone Number
Leave blank if student does NOT have a phone number.
STUDENT Email Address
Leave blank if student does NOT have an email address.
Does your child have any known allergies?
*
Yes
No
List Allergen and Reaction:
Is your child being treated for an injury or sickness or taking any form of medication for any reason?
*
Yes
No
Please Explain:
Does your child require a special diet?
*
Yes
No
Please Explain:
Does your child have or has your child ever had the following?
*
Seizure Disorders
Asthma
Heart Murmur
Diabetes
Hay Fever
Kidney Disease
Sleep Walking
None of the Above
Other
If Any Apply, Please Explain:
Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?
*
Yes
No
Please Explain:
Can your child swim?
*
Yes
No
Family Information
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name 1
*
First Name
Last Name
Parent 1 Phone Number
*
Please enter a valid phone number.
Parent 1 Email
*
example@example.com
Parent/Guardian Name 2
*
First Name
Last Name
Parent 2 Phone Number
*
Please enter a valid phone number.
Parent 2 Email
*
example@example.com
Emergency Contact
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Student's Doctor
Student's Doctor's Phone Number
Please enter a valid phone number.
Health Insurance Company
Insurance Group Number / Policy Number
MEDICAL TREATMENT AUTHORIZATION: I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I give consent to medical and surgical treatment as needed in the judgement of the treating physician chosen by representatives of Cottage Hill Baptist Church or one of its campuses. I also give consent to Cottage Hill Baptist Church or one of its campuses and its representatives permission to transport my child at their discretion in case of an emergency. I agree to notify the church in the event of any health changes which would restrict my child’s participating in any normal church activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.
*
Yes
CONSENT FOR PHOTOGRAPHY AND VIDEOS: I understand and allow photos and videos of my child to be taken while participating in events at Cottage Hill Baptist Church or one of its campuses and to be used in any publications. I also understand that publication of these photographs may be accomplished electronically via the Internet/World Wide Web and that after publication the church will be unable to prevent persons from gaining access to the Internet/World Wide Web, copying my child’s photographs and videos from there, and subsequently using, altering, or republishing them without my consent. I waive any claim for damages against Cottage Hill Baptist Church form unconsented use, altercation, or republication of my child’s photographs and videos by third parties accessing the Internet/World Wide Web.
*
Yes
CONSENT AND CERTIFICATION: I, the undersigned, being the parent or legal guardian of the child named above (the “student”), do hereby consent to the participation of my child/children in all of the regularly scheduled activities of Cottage Hill Baptist Church, Church of the Island, Downtown Church, or Bay Family Church, including transportation and any other activities customarily associated with church activities. Further, I certify that my child is physically fit and adequately trained to participate in such events (except as noted above).
*
Yes
Other Comments
My Name
*
First Name
Last Name
Signature
*
Submit
Should be Empty: