2023-2024 Student Ministries Medical Release Form

Parent/Guardian 1 Information

Name

Address

Phone

You can text me at the above number:

Yes No

This address will receive a confirmation email

My preferred contact method is:

Phone call Text Email

Parent/Guardian 2 Information

Name

Address

Phone

You can text me at the above number:

Yes No

This address will receive a confirmation email

My preferred contact method is:

Phone call Text Email

Student Information

Student's Name

Student's Grade?

Allergies/Conditions/Special Needs?

Student 2

Student's Name

Student's Grade?

Allergies/Conditions/Special Needs?

Student 3

Student's Name

Student's Grade?

Allergies/Conditions/Special Needs?

Health Insurance

Health Insurance Company

Policy Number

Releases and Permissions

I hereby give permission for my student(s), to attend and participate in any student ministry activities during the period of September 1, 2023 – August 31, 2024.

I Agree I Disagree

Should it be necessary for my student(s) to return home due to medical reasons, disciplinary action or otherwise, I shall assume all transportation costs and responsibility. This includes out-of-town events.

I Agree I Disagree

I give permission for my student(s) to ride in any vehicle driven by an approved and licensed adult leader while attending and participating in activities sponsored by Grand Rapids Evangelical Free Church.

I Agree I Disagree

I give permission for photos and/or videos of my student(s) to be taken and used for GREFC ministries. This includes printed material as well as online sources like our website and social media sites. These images will be used for hte sole purposes of building up community, group identity, and communicaton. (If you have quesitons before agreeing or disagreeing, please come talk with us.)

I Agree I Disagree

In case of accident or serious illness, I request the church to contact me first and then my emergency contact. If neither can be reached, I authorize the church to make whatever arrangements seem necessary, including emergency medical transport. I understand that Grand Rapids Evangelical Free Church does not provide any form of health or accident insurance should any injury occur. I also agree that I will not obligate Grand Rapids Evangelical Free Church paid or volunteer staff to pay any medical expenses related to such injury or illness. This form releases Grand Rapids Evangelical Free Church and any staff, paid or volunteer, from any liability.

I Agree I Disagree

I authorize approved adult leaders to administer the following if deemed necessary:

Tylenol Ibuprofin Triple Antibiotic Ointment None

Name of Emergency Contact

Phone Number of Emergency Contact

I understand that my/our email addresses and phone numbers will be used for church purposes only and will not be distributed to any other organization without my consent. GREFC will not add my email address to a subscription list without my consent. My email and cell phone numbers will be used for church communications.

I Agree I Disagree

Signature (Typed Name Qualifies)

Date

2023-2024 Student Ministries Medical Release Form

Description

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