2023 Oxygen Release Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

For students in 6th - 12th grade during the 2023 Calendar year (Jan 1 - Dec 31).

Email *

Student Name (First & Last): *

Student Age: *

Student Birth Date: *

YYYY

Student Address (Street, City & Zip): *

Father/Legal Guardian Name (First & Last): *

Mother/Legal Guardian Name (First & Last): *

Primary Parent Cell Phone (To serve as emergency contact): *

Secondary Parent Cell Phone:

Student School: *

Student Grade: *

GENERAL MINISTRY/TRIP(s)/EVENT(s) CONSENT:

I/we am the parent(s) or legal guardian(s) of this participant, and hereby grant my/our permission for him/her to participate fully in ALL TRIPS AND ACTIVITIES FOR THE CALENDAR YEAR 2023, and hereby give my/our permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. (Valid January 1, 2023 - December 31, 2023) *

Yes (This serves as my/our signature for General Ministry Consent)

MEDICAL RELEASE:

I/we authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general and 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, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my/our child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. *

Yes

Hospital Insurance *

Yes

Insurance Company: *

Policy Number: *

Physician: *

Physician Phone Number: *

List any allergies or special medical problems your child may have: *

Parent with Primary Physical Custody or Legal Guardian: *

I/we authorize medical care for the student named above.

PHOTOGRAPHIC RELEASE:

I/we understand that picture/video may be taken of my student during ministry activities. I/we consent to permit the YOUTH MINISTRY and the CROSSING to use the photos to be exhibited, portrayed or publicized by the Church in promotional, congregational, advertising or other material that the Church reasonably believes will assist the Youth Ministry and the Church in its religious and congregational activities. I/we understand that the photographs may be displayed in digital, print or other formats, in the form of still photographs, motion pictures or videos, transparencies, television or other similar media. They further understand that the photos will not be used in connection with any profit-making activity. I/we the parent, on our own behalf and on behalf of said student, hereby releases the Church and its agents from any and all claims for damages for libel, slander, invasion of privacy or any other claim based on use of the above-described materials. I/we shall be entitled at no charge to a copy of any photo or video made of my/our child by the Church. *

Yes

LIABILITY RELEASE:

Release of All Claims

In consideration for being accepted by Washington Crossing United Methodist Church for participation in ALL TRIPS AND ACTIVITIES FOR THE CALENDAR YEAR 2021, I/we, being 21 years of age or older, do for myself/ourselves (and for and on behalf of my child-participant if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless Washington Crossing United Methodist Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above-described trip or activity. Furthermore, I/we (and on behalf of my/our child-participant if under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Furthermore, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. The undersigned does herby give permission for my/our child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Washington Crossing United Methodist Church. The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. Furthermore, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs. *

Yes

FINAL SIGNATURES:

Name of Participant/Student: *

Name of Parent/Legal Guardian: *

I have read the foregoing and understand the rules of conduct for participants and will abide by them as well as the directions of the leadership of the trip. *

By checking this box, I verify this as my signature.

Required

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Washington Crossing UMC. Report Abuse

Forms