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2026 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 2026 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 2026 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: April 2, 2026

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 2026 year.


Date: April 2, 2026



First Student's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Student's Date of Birth*
Date of Birth
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*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
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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