Crossroads Student Ministries Medical Release and Event Permission for all events in 2022:
In the event of a medical emergency, procedures must be clearly outlined and understood by both parents and leaders.  If you list the names of all your children on this form, it will not be necessary to complete a separate form for each child.
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Email *
Child/Children's Name(s)/Birth Dates *
Parent/Guardian Name(s) *
Address: *
Parent Cell Phone: *
Parent Email Address:
Family Doctor & Phone Number: *
Health Insurance/Policy Number: *
Would you like to use Parent Info as Emergency Contact? *
If no, please provide Emergency Contact Name and Number:
Does your child have any allergies or health problems of which we should be alerted? (If none, please answer "No.") *
  In the event of illness or medical emergency, the leader will attempt to contact parents for instructions. If the leader is unable to contact you, the leader will have the authority to have the child treated by any licensed physician and/or surgeon who may perform such procedures or administer such medications as the emergency requires for the relief of pain or to preserve life and health.  In non-medical emergencies, the leader will take what action seems to be normal and appropriate.
By signing at the bottom of this page, I hereby agree that I have read the above policy and am in agreement with its provisions in total. I also assume financial responsibility for use of an ambulance to transport my child to the nearest health care facility should such a need arise. * *
EVENT PERMISSION: I hereby give my permission for my child/children (Name mentioned above) to go with Crossroads Church to any offsite trips/events from , January 1st, 2022 through December 31st, 2022. By signing below, the parent/guardian gives consent to the said child to participate in a church sponsored activity. The undersigned agrees to hold harmless (which means to not assign blame or legal responsibility) Crossroads Assembly of God, its officials and those workers assisting in the activity from any and all harm that may be sustained as a result of or during the activity, including transportation to and from the activity. Parent further agrees to resolve any dispute arising from any harm where the matter is, by mutual consent, deemed not covered by this consent or over the consent itself, by submission to binding arbitration. *Please Print Full Name Below- This will be your Digital Signature *
A copy of your responses will be emailed to the address you provided.
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