YTH MEDICAL RELEASE FORM

Parents/Guardians: Please fill out this permission form so that your child may participate in all youth activities and events.

PARENTAL CONSENT, CERTIFICATION, AND MEDICAL AUTHORIZATION.

Parents and legal guardians of students 6-12 grade, are asked to complete this form. The information requested is designed to assist the Student Ministry, in providing for the safety of our youth during church-sponsored activities and events.

STUDENT INFORMATION

Student Legal Name

Date of Birth

Student Age

Student Current Grade

Address

Phone

GUARDIAN INFORMATION

Mother/Legal Guardian

Name

Address

Phone

Father/Legal Guardian

Name

Address

Phone

EMERGENCY CONTACT

Name

Phone

Relationship to Student

Parent/Legal Guardian Signature

I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in all the regularly- scheduled activities of the Student Ministry at Temple City Church. Including but not limited to: Mission trips, camp outs, student conferences, swimming, boating, hiking, fundraisers, camp, events at camp, sporting events, and any other activities customarily associated with Temple City Church student ministry. Further, I certify that my child is physically fit and adequately trained to participate in such events, including swimming. I also consent to my child riding in a vehicle driven by a chaperon, one of our qualified student leaders or a qualified driver assigned to us through a transit company, such as a charter bus.

I understand that this form is good for 12 months, and must be re-signed at the conclusion of the 12th month.

I understand by typing my name in the signature box that this serves as an electronic signature on the above statement.

Electronic Signature

Date Signed

MEDICAL INFORMATION

Insurance Carrier (Optional)

Policy Number (Optional)

Policy Holders Name (Optional)

Policy Holder's Relationship to Student (Optional)

If insurance is through your employer please list the following: (Optional) Company/Employer: Name, Address, Phone Number & Occupation

Upload Copy of Insurance Card (Optional)

Upload (8MB)

MEDICAL QUESTIONNAIRE

Is your child presently being treated for an injury or sickness?

Yes No

If yes, please specify the injury or sickness (Optional)

Is your child currently taking medications?

Yes No

If yes, please list medications and dosage prescribed (Optional)

Is your child allergic to any type of medication?

Yes No

If yes, please list medication allergy (Optional)

Does your child have any allergies?

Yes No

If yes, please list all (food, seasonal, etc) (Optional)

Does your child require medications for any allergies (such as: Epi pen, Benadryl, etc?)

Yes No

If Yes, please list medications (frequency and dosage) (Optional)

Does your child require a special diet?

Yes No Option

If Yes, please specify what their needs are: (Optional)

Does your child have/or has ever had any of the following:

MIGRAINES/FREQUENT HEADACHES STOMACH ISSUES ASTHMA KIDNEY/HEART DISEASE SEIZURE DISORDER OTHER NONE OF THE ABOVE

If "Other", please specify the medical condition/actions needed (Optional)

Does your child sleepwalk?

Yes No

Can your child swim?

Yes No

Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?

Yes No

If Yes, please specify condition and limitations (Optional)

Any other information that you would like to specify about your child, please do so below (Optional)

Parent/Guardian Signature

I am aware that my child taking part in, or participating in all youth related activities, could involve the risk of injury. I hereby agree to let my child participate and to hold Temple City Church harmless from any and all liability actions, courses of action, debts, claims, or demand of any kind and nature whatsoever which may arise by or in connection with my child participating in any activites. Because of the risks involved, I will encourage my child to follow the instructions of the supervising adults and leaders. My permission is granted for supervising adults and/or leaders to obtain medical and surgical treatment as may be needed in the judgement of the treating physician, for my child. And by a physician chosen by the church chaperone.

I also understand that as a participant, my child may be photographed or videotaped during church.

I understand by typing my name in the signature box that this serves as an electronic signature on the above statement.

Electronic Signature

Date Signed

YTH MEDICAL RELEASE FORM - Winter Weekend 2025

Description

YTH MEDICAL RELEASE FORM - Winter Weekend 2025

Description

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