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Medical Release and Permission Form
General Information
This document requires a digital signature in multiple places. Each time you click the check box, you validate an electronic signature. By checking this box, you are digitally signing this document. Do you agree to the terms stated in this document and further certify that checking the boxes counts as an electronic signature?
Yes
Youth First Name
Youth Last Name
Birthdate
Parent(s) Names
Address
City
State
Zip
Parent email address
Student email address
Parents Phone Number
Student Phone Number
School
Grade in School
Alternate contact in case we cannot reach you:
Relationship to child:
Phone Number For Alternate Contact:
Do we have permission to use your student's photo (no name listed) on our website?
Yes
No
Does your student have any allergies? If yes, please list:
Does your student take medication regularly? If yes, please list:
Does your student have other medical/physical conditions or limitations of which we should be aware: (such as asthma, diabetes, a heart condition, etc.) If yes, please list:
Medical Release Form:
In case of injury & I am unable to be contacted after a reasonable attempt has been made, the representative of Emmanuel Presbyterian Church is hereby authorized to act on my behalf should my child need medical attention:
Yes
No
Insurance Company and policy number
Permission Form: Consent and Release form Liability
My child (list name):
....has permission to participate in all youth activities sponsored by Emmanuel Presbyterian Church including, but not limited to: Bible studies, overnight retreats, service projects, youth group meetings, and more. In consideration of the benefits to be derived from these activities, I release, discharge and hold harmless Emmanuel Presbyterian Church, their employees or those supervising these events from any and all claims arising from my child’s participation in these activities, or as a result of injury or illness of my child during these activities.
Yes
No
Signature of parent/legal guardian
Date
Submit
