Student Release Form

Please take a moment and fill out your students release form! You can request a blank, paper copy of this form here.

Students Name

First Name

Last Name

Nickname

Students Email (only if 13 or older)

Grade

Date of Birth

YYYY

School Attending

Male/Female

Student Cell Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Email

Parent/Guardian Cell

(###)

###

####

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Email

Parent/Guardian Cell

(###)

###

####

Non-Parent Emergency Contact

First Name

Last Name

Relationship to Student

Emergency Contact Number

(###)

###

####

Medical Insurance Company

Medical Insurance Phone

(###)

###

####

Policy/Group ID Number

Policy Holders Name

Date of last Tetanus Toxoid Immunization

YYYY

List any chronic medical conditions (asthma, diabetes, anxiety, etc.)

Type N/A if none

List any allergies

Type N/A if none

List any medication student may need to take during the course of ministry activities and dispensing instructions (i.e. 20 mg of Aleve to relieve migraines) or mark N/A

Type N/A if none

Preferred Hospital

Please Choose

I DO/DO NOT give permission for an adult Student Ministry leader or Restore Staff member to give my child/dependent approved over-the-counter medications as directed by the medication’s labeling on an as needed basis to treat non-emergency medical conditions.

DO NOT

Please Choose

I DO/DO NOT give permission for Student Ministry leaders and Restore Staff to photograph and record my child/dependent’s likeness and activities during ministry-related activities, including rights to use and re-use, publish and re-publish, and modify or alter these images for editorial, commercial, trade, advertising, and any other purpose which may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.

DO NOT

Please Choose

I DO/DO NOT give permission for my child/dependent to ride in any vehicle driven by an approved and licensed adult chaperone, Student Ministry leader, or Restore Staff while attending and participating in activities sponsored by Restore Church. My child/dependent and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

DO NOT

Release Statement

MANDATORY RELEASE STATEMENTS The following are required for participation in any Student Ministry activity at Restore Church: I, the undersigned, allow my child/dependent to participate in Student Ministry (Sunday worship, Activities, Events, Retreats, Lock-Ins, Trips, etc.), and do hereby release, forever discharge and agree to hold harmless Restore Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by myself and my child/dependent during said participation. I also agree to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of my child/dependent, including expenses incurred attendant thereto. I authorize an adult, in whose care my child/dependent has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. I understand I shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to my child/dependent pursuant to this authorization. Should it be necessary for my child/dependent to return home from any activity due to medical reasons, disciplinary action or otherwise, I shall assume all transportation costs and responsibility. This release statement will be used as continued permission until the named student turns 18 years of age. By signing below, I agree to the previous statements and certify that the information given is true, accurate, and complete to the best of my knowledge:

Date

YYYY