Medical Release and Permission Form

Birthday *

MM

DD

YYYY

Gender *

Male

Female

Phone *

Home or Cell

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mother/Guardian's Name *

First Name

Last Name

Mother/Guardian's Cell Phone *

(###)

###

####

Mother/Guardian's Work Phone

(###)

###

####

Father/Guardian's Name *

First Name

Last Name

Father/Guardian's Cell Phone *

(###)

###

####

Father/Guardian's Work Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact's Cell Phone *

(###)

###

####

Emergency Contact's Work Phone

(###)

###

####

Office Phone *

(###)

###

####

Office Phone *

(###)

###

####

For your child's safety and our knowledge, is your student a: *

Good swimmer

Fair swimmer

Non-swimmer

Other

Does your child have allergies to: *

Pollens

Medications

Food

Insect Bites

None

Does your child suffer from, or has ever experienced, or is being treated currently for any of the following: *

Asthma

Diabetes

Epilepsy/Seizure Disorder

Frequently Upset Stomach

Heart Trouble

Physical Handicap

Other

None

Date of last tetanus shot: *

MM

DD

YYYY

Student Statement and Release *

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct.

Yes.

Parent Statement and Release *

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. My child has my permission to attend all youth activities sponsored by New Life Church (hereinafter the "Church") from June 2025 to August 2026. 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 the 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.

Yes.