2022-2023 Grace Bible Church Student Participation & Annual Release Form (6th-12th Grade; September 1, 2022

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2022-2023 Grace Bible Church Student Participation & Annual Release Form (6th-12th Grade; September 1, 2022 - August 31, 2023)

Grace Bible Church
6023 Dutton Place
Newfane, NY 14108
(716)778-9081

Contact: Pastor Matt Weir
C: (312)420-5665
E: mweir@gbcnewfane.com

Email *

RELEASE FORM

Please read and sign the annual release form below.

Name of minor: *

I/We give consent for (name of minor above) to attend any Student Ministries events being sponsored by Grace Bible Church from September 1, 2022 through August 31, 2023. In the event that he or she is injured while under the care of Grace Bible Church and its representatives and requires the attention of a doctor, I hereby consent to and will be responsible for any reasonable medical treatment as deemed necessary by a licensed physician. I/We further agree to hold the licensed physician, the medical facility, Grace Bible Church and its representatives free and harmless of any claims, demands or suits for damages rising from the authorization and provision of such medical treatment. I/We understand the nature of the events and do hereby release Grace Bible Church and its representatives from any liability due to accident or injury incurred by my child. *

By checking this box and typing my name below, I am electronically signing this release form.

Required

Type in your full legal name. *

Type in today's date. *

YYYY

CONTACT INFORMATION

Every possible safety precaution will be taken by those in charge and every possible attempt will be made to contact the parent or guardian immediately in the event of injury or other emergency.

Name of Parent/Guardian *

Address *

City *

Phone (Cell) *

Phone (Other) *

Email *

Minor's DOB *

YYYY

Grade of Minor *

Age of Minor *

Minor's Gender *

Male

Female

Required

Special Concerns, Medications or Allergies (including food allergies/sensitivities) *

The following medications may be given to my child if needed: *

Ibuprofen

Tylenol

Benadryl

Antibiotic Ointment

TUMS, Maalox, Pepto Bismol

Anti-diarrheal (i.e. Immodium)

Benadryl Anti-Itch Cream (i.e. Benadryl/Hydrocortisone)

Cough drops

Cough syrup/Robitussin CF

Any of the above

None of the above

Required

Family Doctor *

Family Doctor's Phone Number *

Insurance Company *

Name of Policy Holder *

Group/Policy # *

Emergency Contact if Parent/Guardian unable to be reached *

Emergency Contact's Phone *

Emergency Contact's Relationship to Minor *

Home Church (if applicable)

People authorized to drop off/pick up my child (other than listed above) *

My child has permission to walk home from church *

Yes

My child has permission to ride home with a leader *

Yes

Grace Bible Church has my permission to use pictures of my child in church brochures, posters, outreach material, church web pages, etc. *

Yes

SIGNATURE *

By checking this box and typing my name below, I am electronically verifying this contact information is true and correct.

Required

Type in your full legal name. *

Type in today's date. *

YYYY

Send me a copy of my responses.

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