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Student Medical and Travel Release Form 2024/2025


The following health record must be filled out for each student by the parent or legal guardian. The student may not be a part of any College Church extracurricular activity until we have a completed form on file. A new form must be filled out at the beginning of each school year.  If you have any questions, please contact a College Church ministry staff member.

Treatment: In case of emergency, I hereby give permission to the physician selected by the College Church staff and/or assigned personnel to hospitalize, secure treatment for, and to order injection, anesthesia, and/or surgery for the student named above.

Punctuality: I agree that my student should be punctual for designated departure times. If my student is more than 15 minutes late for an announced departure, I understand that College Church may leave for the event without my student. I agree that it is my responsibility to ensure that my student is picked up at the designated time at the church. I understand that College Church reserves the right to exclude my student from future events if I am continually late in either dropping off or picking up my student.

Dated: May 14, 2025

First Participant's Name
First Name*
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Third Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Fourth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Fifth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Sixth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Seventh Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Eighth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Ninth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Tenth Participant's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Participant's 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's or Guardian's Email Address
Email*
Confirm Email*
Medical Insurance Information
Insurance Company
Phone
Address
City
State
Zip
Policy Number
Group Number
Insurance Card Holder
Parents/ Legal Guardian Info
1) Name: *
Contact Number *
Email *
2) Name:
Contact Number
Email
Emergency Contact Information (secondary to the Parents/Guardians above)
Name *
City *
State *
Phone *
College Church Photo Release

I hereby grant to The College Church of the Nazarene, Inc. (CCN), a Kansas corporation, and those acting pursuant to CCN’s authority, the right to use my photograph(s), without my name in conjunction with its exhibition, on its website or in other official church publications, printed, online, or otherwise, without further consideration.

 

I acknowledge the church has the right to crop or treat the photograph(s) at its discretion.

 

I also acknowledge that the church may choose not to use my photograph(s) at this time, but may do so at its own discretion at a later date.

 

I also understand that once my image is posted on the church’s website, the image can be downloaded by any computer user, anywhere in the world. 

 

Therefore, I agree to indemnify and hold harmless the church, its pastor, associate pastors, its church board members and designees from any claims arising out of the use of my photograph(s).

 

The church reserves the right to discontinue use of any photograph(s) without notice.

If a dispute over this agreement or any claim for damages arises, I agree to resolve the matter through a mutually acceptable alternative dispute resolution process. If I cannot agree with Church upon such a process, the dispute will be submitted to a three-member arbitration panel of the American Arbitration Association for final resolution.

 

By signing this document, I understand that:

The photographs will only be used for not-for-profit purposes

The photographs cannot be edited or changed in any way without the consent of CCN

The photographs become the property of CCN

I waive the right to inspect or approve the finished product, including written or electronic copy, where my likeness appears

My name will not be published in conjunction with my likeness.

RENUMERATION: It is understood between both parties that there will be no renumeration.


Click Yes to approve or No to opt-out:*
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's or Guardian's Name
First Name*
Last Name*
Phone*
Select Gender
Participant's Date of Birth*
Date of Birth
Parent's or Guardian's Information
Current Grade *
Height *
Weight *
Hair Color *
Eye Color *

Are there any family or guardianship concerns that the church should be made aware of for safety purposes only?

Medical History


Please list any medical/health concerns or handicaps that we should be aware of
Allergies
Drug allergies
Date of last tetanus shot
Student's Doctor's Name *
Doctor's Phone Number *
Parent's 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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