CCC YOUTH MINISTRY CHURCH RELEASE FORM

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Name of parent or guardian *

Name of student *

Student's Birthday *

YYYY

Date you are filling this form *

YYYY

Release Statement

My child is attending and participating in activities at Community Christian Church, Salisbury, MD 21801.

I hereby authorize the Youth Pastor, Ryan Fitzgerald, and his/her officers, agents, servants, or employees who are 18 years of age or older, who supervise the activities at Community Christian Church, into whose care my child has been entrusted, to consent to emergency medical care or dental care, or both, for my child.

I further authorize the Youth Pastor, Ryan Fitzgerald and his/her officers, agents, servants, or employees who are 18 years of age or older, who supervise the activities at the Community Christian Church to receive physical custody of my child.

I hereby waive my rights to bring any suit against Community Christian Church for any reason, while my child is under their supervision.

It is understood that this authorization is given in advance of any special diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of the supervisor and his/her authorized designee, in the exercise of his/her best judgment on what is advisable for my child’s care, upon advice of such physician, dentist, and surgeon.

Yes, I agree to the above release statement. Selecting this option WILL allow your student to participate in youth group activities.

No, I do not agree to the above release statement. Selecting this option will NOT allow your student to participate in youth group activities.

Parent/Guardian Name(s) *

Name of Child *

Current Grade of Child *

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Address, City, State & Zip Code *

Primary Contact's Phone Number *

Primary Contact's Preferred Email Address *

In case of emergency, please list any contacts (phone number and relationship to student) below. *

Please provide the student's Medical Insurance Company's name and policy number below. *

Please list or describe any allergies or medications your child has below. You may also write down other information that a doctor should know about your child's health.

You may write down any additional notes or comments below.

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