Student Ministry - Medical Release and Consent

Student Name *
Student Name
Student Date of Birth
Student Date of Birth
Student Cell Phone
Student Cell Phone
Home Address *
Home Address
Home Phone
Home Phone
Mother's/Guardian's Name
Mother's/Guardian's Name
Mother's Cell
Mother's Cell
Father's/Guardian's Name
Father's/Guardian's Name
Father's Cell
Father's Cell
Physician Office Phone Number *
Physician Office Phone Number
Emergency Phone Number *
Emergency Phone Number
Immunizations
Check the box below to agree to the following: *
I hereby give permission for the above-named student (herein “Student”) to participate in the above- named event and its related activities, including without limitation transportation to and from such activities, if applicable (herein “Event”) as organized by Third Church in Richmond, VA (herein “Third”). I hereby release, hold harmless and absolve Third, its officers, trustees, employees, staff, sponsors, vendors, volunteers, and all others who have participated in the planning, organizing and implementing of the Event, be they individuals or organizations, singly or collectively, from responsibility with respect to Student’s participation in the Event. If the Student is a minor, in the event of a medical emergency in which the Emergency Contact Person named above cannot be reached after reasonable effort has been made to secure personal consent, I authorize any and all treatment of the Student which is medically necessary in the opinion of the attending physician. If the Student has any medical conditions or is taking any medications which may be relevant to a physician in the event of a medical emergency, I have listed them above. I hereby release and discharge Third and all affiliated entities from any and all claims, demands, or causes of action that I have in connection with the use and exercise of the rights granted in this release.
Printed Name *
Printed Name
Your name serves as your signature
Media Release *
Third may tape or photograph Student and record his/her voice during his/her participation in the Event and that Third may use any such recordings or photographs, in whole or in part, whether in original or modified form, in any manner or media, for the purpose of advertising, promoting, and publicizing Third whether during the Event or thereafter.