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2024 HSM/MSM Medical Release and Participation form

I acknowledge that my child's participation in any CGCC youth activity presents risks that I or my child may suffer including, but not limited to, damage or loss of personal property, financial damage, emotional injury, bodily injury, or illness. I (we) herby assume those risks. I (we) release CGCC and its respective agents from any claims or liability for injury or damage, and assume all risks from my child's participation in ANY CEDAR GROVE SPONSORED ACTIVITIES IN THE YEAR 2024.

If during a Cedar Grove Community Church (CGCC) sponsored activity, I (we) and/or my student's alternate emergency contact are unable to consent in the case of emergency, I (we) hereby give permission to the licensed physician or hospital selected by CGCC to hospitalize, secure proper treatment for, and order injection, anesthesia, x-ray, or surgery for my student. I (We) certify that I (we) am responsible for any health insurance or resources needed to cover the costs of treatment in case of any such injury or illness needed for my student in the case of a medical emergency. 

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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Insurance

Insurance Carrier*

Insurance Policy Number*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Participant Expectations
  • Respect one another, staff, and leaders
  • Respect property
  • Students are not permitted to drive for events
  • No fighting, weapons, fireworks, explosives, or lighters
  • No alcohol, drugs, tobacco


I acknowledge these rules of conduct expected from each student participant and parent.
Photo Release

I give consent for my child's image to be photographed or filmed for use in CGCC video presentations, printed materials, social media, web site, parent newsletters, and other church materials and publications.

Students will not be identified by first or last name in any physical or online publications.

Yes
No
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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