Student Release

Student Name *

First Name

Last Name

Student Phone

(###)

###

####

Student Birthdate *

Required

MM

DD

YYYY

Parent #1/Guardian Name *

First Name

Last Name

Parent #1/Guardian Phone *

(###)

###

####

Parent #2/Guardian Name

First Name

Last Name

Parent #2/Guardian Phone

(###)

###

####

Physician Phone *

(###)

###

####

Immunizations

Tetanus

Polio

MMR

DPT

Indicate the student's comfort level with swimming:

Strong swimmer; can swim independently

Novice; uncomfortable swimming independently

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

I hereby give permission for the above-named student (herein “Student”) to participate in Third Student Ministry events and programs, 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 or program, be they individuals or organizations, singly or collectively, from responsibility with respect to Student’s participation in the Event or program. 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. *

Required

Yes

I give permission to the student ministry staff and/or volunteers to contact me and/or my student(s) about student ministry related programs and events. *

Required

Yes

No

I give permission for the Third Student Ministry staff and/or volunteers to meet one-on-one with my student(s) in a public setting, should the need or occasion arise.

Yes

No

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. *

Required

I agree

I do not agree