Youth Medical & Media Release 2023
This is a medical release form for all youth ministry activities at Swift Creek Presbyterian church for the year 2021.
Student Name
*
Date of Birth
*
Grade
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Student Cell
*
Student Email
*
Student Cell
*
Parent's Email
*
This address will receive a confirmation email
Parent's Cell
*
Alt. Emergency Contact Name
*
Alt. Emergency Phone
*
Student Relationship to Alt. Emergency Contact
*
Medications (Prescriptions and OTC)
*
Allergies/Allergic Reactions
*
Other Important Health Information
*
Physician Name
*
Physician Phone
*
Medical Insurance Provider and Policy #
*
I, the parent or guardian of the student listed in this document, hereby authorize emergency medical, dental, health or hospital services to be rendered to my child upon consent of a Swift Creek Presbyterian Church pastor, staff or designated advisor between June 1 and December 31, 2023. The purpose of this authorization is to permit my child to receive emergency medical attention, when needed, while involved in activities connected with the Swift Creek Presbyterian Church youth ministry when neither I nor my emergency contact are available to give such consent.
*
Please select one option.
Agree
I, the parent or guardian of the student listed in this document, release discharge and hold harmless from liability Swift Creek Presbyterian Church, and its employees, agents, and all persons acting on behalf of such 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 the above named participant while involved in the youth activities and between June 1 and December 31, 2023. I also agree to indemnify the church and its employees, agents and all persons acting on its behalf for any liability or damages relating to the same. I understand that this is a legally binding release and agreement to indemnify.
*
Please select one option.
Agree
IF PARTICIPANT IS AGE 18 OR OLDER: I am 18 years old or older and agree to release, discharge and hold harmless from liability Swift Creek Presbyterian Church, and its employees, agents and all persons acting on behalf of such church, for any and all claims relating in any way to my participation in youth ministry activities between June 1 and December 31, 2023. I also agree to indemnify the church and its employees, agents and all person acting on its behalf for any liability or damages relating to the same. I understand that this is a legally binding release and agreement to indemnify.
Please select one option.
Agree
FOR ALL STUDENT PARTICIPANTS: I, as a participant on any events with the Swift Creek Presbyterian Church Youth Ministry agree to follow all of the rules of the event and listen to all leaders and their instructions during the event. I understand that my cooperation in this will help the event be successful.
*
Please select one option.
Agree
MEDIA CONSENT I give my consent and permission for the taking of photographs and/or video of my student during 2023 Mission Trip and waive and/or assign any and all rights (including copyright) in such media to SCPC for promotional use in print and online. SCPC will not use their full names with the picture of the students on their website, nor will it tag any student used on SCPC or the John 21 Student Ministry facebook pages.
*
Please select all that apply.
Agree
Option
Option
Submit
Description
This is a medical release form for all youth ministry activities at Swift Creek Presbyterian church for the year 2021.
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