CPC Student Ministry Permission Form & Medical Release

I, being the parent / legal guardian of the minor identified below, am completing this form as an expression of consent and agreement that said son or daughter / minor may travel with the Centreville Presbyterian Church Student Ministry for the event or purpose as identified below.

Your name *

Email address *

Phone number *

Minor's Full Name *

Minor's Age *

max: 17

Address *

Student Ministry Event / Purpose of Travel *

Event Duration *

I give permission for CPC to take and use my child's photo for CPC's website and/or social media.

Yes

I know CPC does its best to keep kids safe, but I understand that accidents can happen. I won’t hold CPC, its staff, or volunteers responsible if my child gets hurt during a ministry event. *

ALTERNATE EMERGENCY CONTACT

(If parent/guardian is unavailable)

Emergency Contact Name *

Phone Number *

Relationship to Student *

MEDICAL RELEASE

I also consent for the youth leaders to secure the administration of medical treatment and/or medication for the above named child. I further agree to the performance of such treatment, anesthetic, and operations as in the opinion of the attending physician is deemed necessary.

List any medications or treatment below that should NOT be given because of dangerous reactions:

AUTHORIZATION

Signature *

Please type your name below as agreement to all the above.

Today's Date *

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