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Medical Release & Permission Form 

Effective dates:  September 1, 2024 - August 31, 2025

For your information, we expect each student to conform to these rules of conduct:

  • possession or use of alcohol, drugs, or tobacco is prohibited.
  • Students may not drive other students for events (unless by permission of youth pastor and parent/guardian)
  • Fighting, weapons, fireworks, lighters, or explosives is prohibited.
  • Offensive or immodest clothing is not allowed
  • No boys in girls' sleeping quarters and no girls in boys' sleeping quarters
  • Participation with the group is expected
  • Respect property
  • Respect one another, staff, and adult leaders
  • Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home at their parents' expense.

I, the parent/guardian, state that my child has read and agrees to the above rules of conduct.

Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller-skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: If you desire to limit your child's participation in any event, please submit your wishes in writing to the church youth pastor prior to that event. 

Student has my permission to attend all youth activities sponsored by Grace Church Student Ministries (herein after the "Church"). This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. 

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. 

I also give permission to use any photos taken during these activities that my student may be in for use on social media, publication and/or promotion.

Parent/guardian signature:

Today's date: February 7, 2025

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Third Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Fourth Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Fifth Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Sixth Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Seventh Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Eighth Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Ninth Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Tenth Participant's Name

First Name*

Middle Name

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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:*
Insurance

Insurance Carrier*

Insurance Policy Number*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Dentist

Dentist

Office phone
Physician

Physician

Office phone
NEW section

Medical Release & Permission Form 

Effective dates: September 1, 2023- August 31, 2024

For your information, we expect each student to conform to these rules of conduct:

  • No possession or use of alcohol, drugs, or tobacco
  • No students can drive other students for events (unless by permission of youth pastor and parent/guardian)
  • No fighting, weapons, fireworks, lighters, or explosives
  • No offensive or immodest clothing
  • No boys in girls' sleeping quarters and no girls in boys' sleeping quarters
  • Participation with the group is expected
  • Respect property
  • Respect one another, staff, and adult leaders
  • Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home at their parents' expense.

I, the student, have read the rules of conduct, and agree to abide by them.

Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller-skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: If you desire to limit your child's participation in any event, please submit your wishes in writing to the church youth pastor prior to that event. 

Student has my permission to attend all youth activities sponsored by Grace Church Student Ministries (herein after the "Church"). This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. 

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. 

I also give permission to use any photos taken during these activities that my student may be in for use on social media, publication and/or promotion.

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

Age

Year in school

Medical History. 

Check the following areas of concern for this student.

1. Does your child have allergies to:
pollens
medications
food
insect bites
2. Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
asthma
epilepsy/seizure disorder
heart trouble
diabetes
frequently upset stomach
physical handicap

3. Date of last tetanus shot:

4. Please list and explain any major illnesses the child experienced during the last year:

5. If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken

6. Should this child's activities be restricted for any reason? Please explain:

Any Additional Information
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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