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STUDENT ACTIVITY & MEDICAL RELEASE FORM


PARENTAL CONSENT

The undersigned does hereby give permission for my child, listed above, to attend and participate in any WECC youth ministry activities, events & retreats. This form applies for ALL activities within 1 year of the date above.

LIABILITY RELEASE: In consideration of WECC allowing the Participant to participate in youth ministry (Sunday worship, DGROUPS, Activities, Events, Retreats, Trips), I, the undersigned, do hereby release, forever discharge and agree to hold harmless WECC, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in youth activities. I the, parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by WECC. My youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

PHOTOGRAPHY PERMISSION: I authorize WECC and representatives, agents, employees, shareholders, officers, directors, partners, and heirs to use my or my student's image, photograph, or other artwork in one or more of its products, advertising, web page, and promotional material. I give WECC permission to use, copy or modify such materials for one or more of its products and advertising. I release WECC from any claims or actions of liability that may arise from the adaptation of the materials for WECC's products and advertising. Furthermore, I understand that by signing, I am releasing WECC from any liability for compensation for such materials.


Today's Date: May 11, 2025

Please select who will be participating...
Minor
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First Student's Name

First Name*

Middle Name

Last Name*
First Student's Date of Birth*
First Student's Information

Cell Phone (if applicable)

School

Grade*

School *
First Student's Signature*
Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent / Guardian Information

Parent / Guardian #1 Name *

Parent / Guardian #1 Cell Phone *

Parent / Guardian #2 Name

Parent / Guardian #2 Cell Phone
Emergency Contact

Name *

Relation *

Cell Phone *
Medications / Health Information

Medications


List all medications your student will take during any youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Please list medication, dose & time of day medicine is taken.
Over-the-Counter Medication Permission: Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat nonemergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?*
No. Contact me or get medical help if my child has any minor medical concerns.
Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.

Health Information


Please list any medications medical conditions you would like us to be aware of in case of an emergency.

Primary Care Physician


Name of Physician *

Phone Number *

Name of Practice *

Date of Last Tetanus Shot

Insurance Information

Please either fill out or attach a copy (front & back) of your insurance card.


Insurance Company

Policy Holder's Name

Policy/Group ID #

Phone Number
  
Insurance Card Upload
Valid file types: JPG, GIF, PNG, and PDF
Parent or Guardian's Email Address

Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Cell Phone (if applicable)

School

Grade*

School *
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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