Student Medical Information
If conditions do not apply please indicate not applicable
We will be corresponding primarily by email, if you would like to recieve our notification please provide a parent email! Thank you
Emergency Contact OTHER than Parent
1). I do hereby verify the information given on this form is correct and acknowledge that this release is effective from Sept. 1, 2021, through Sept. 1, 2022, and it is my responsibility to notify student ministries of any occurrence of changes to the information provided.
2). I do hereby give permission for my student to be transported to and from all events by either Student Ministries Staff, Student Ministries Staff Volunteers and/or Student Ministries Hired Transport.
3). I authorize the administration of any over the counter medications by a student ministries staff member/approved adult volunteers/hired healthcare professional. I also authorize any health care professional to treat for injury or illness and to release information for insurance purposes.
4). I understand that any prescribed medication will be administered by the student and will not hold the student ministries staff/volunteer or hired healthcare professionals responsible for housing or administering prescribed medication.
5). I agree to assume the obligation of doctors' bills or other expenses relating to an emergency incurred during the period of these activities, events, or trips.
6). I assume all risks and hazards incidental to the conduct of activities, events, or trips and transportation to and from activities, events, or trips. In case of injury or damage to my student, I hereby waive all claims against Christ the Rock Community Church, its employees, volunteers, or any supervisors appointed by them. I likewise release from responsibility any person transporting my student to and from activities, events, or trips.
7). I give permission to Christ the Rock Community Church's student ministries to include my student in pictures and videos to be used for Student Ministries multi-media purposes.
8). I agree to bring my student home at my own expense should my student become ill/be deemed ill or if it is deemed necessary by the Student Ministries Staff.
9). I acknowledge that if I choose to later revoke this permission and medical release it must be done in writing.
10). I am allowing my student to attend Student Ministry functions with Christ the Rock Community Church and voluntarily assume all risks related to the exposure of COVID-19 for my student, my family, and/or anyone else we may come in contact with.
**I acknowledge that my Electronic Signature is my authorization for all of the above permission and medical agreement.