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2024 VINEYARD COMMUNITY CHURCH YOUTH MINISTRY PERMISSION/MEDICAL RELEASE FORM 


 

PERMISSION AND RELEASE

As the parent (or guardian) of the below named attendee, I grant permission for my son or daughter to attend Vineyard Community Church 2024 activities and events and authorize Vineyard Community Church and its chaperons, to transport and supervise my student in connection with his or her attendance at the various activities throughout the 2024 year.

I do further hereby give, release, absolve, indemnify, and agree to hold harmless, Vineyard Community Church, staff, volunteers, and persons transporting my son/daughter to and from the activity and associated activities from any claim arising out of injury to my son or daughter. 


Date: December 21, 2024

MEDICAL CARE AUTHORIZATION

As the parent (or guardian) of the below named attendee, I hereby authorize Vineyard Community Church and its chaperones to seek and have emergency medical first aid administered to the above named attendee during the 2024 year.


Date: December 21, 2024



First Student's Name

First Name*

Middle Name

Last Name*

Phone*
First Student's Date of Birth*
First Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
First Student's Signature*
Second Student's Name

First Name*

Middle Name

Last Name*

Phone*
Second Student's Date of Birth*
Second Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Third Student's Name

First Name*

Middle Name

Last Name*

Phone*
Third Student's Date of Birth*
Third Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Fourth Student's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Student's Date of Birth*
Fourth Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Fifth Student's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Student's Date of Birth*
Fifth Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Sixth Student's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Student's Date of Birth*
Sixth Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Seventh Student's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Student's Date of Birth*
Seventh Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Eighth Student's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Student's Date of Birth*
Eighth Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Ninth Student's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Student's Date of Birth*
Ninth Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Tenth Student's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Student's Date of Birth*
Tenth Student's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
Student'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 or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Person to call if Primary Emergency Contact cannot be reached:

Name *

Phone *
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Information
Are there any special health conditions of which Vineyard Community Church should be aware (such as allergies to medicines or bee stings, epilepsy, heart conditions, etc.)?*

If the answer to the preceding question was "Yes," please explain in detail:
Does your student know how to swim?*
If yes:
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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