Immanuel Youth Ministries Medical Release and Photo Release Form
Please fill out this form and update it if/when information changes.
Parent Information
Parent's Name
*
Email
*
This address will receive a confirmation email
Home Phone
*
Cell Phone
*
Address
*
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AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Relationship to Youth
*
Youth Information
Name
*
Birth Date
*
Gender
*
Please select one option.
Male
Female
Select Option
Male
Female
School
*
Grade
*
Please select one option.
4
5
6
7
8
9
10
11
12
Select Option
4
5
6
7
8
9
10
11
12
Emergency Contact
Emergency Contact Name
*
Emergency Contact Phone Number
*
Insurance Information
Company
*
Policy Number
*
Medical Information
Family Doctor
*
Family Doctor Phone Number
*
Allergies
Medication Being Taken
Release and Signature
I give my consent for Immanuel Youth Ministries counselors, staff, and chaperones to take my child listed above on offsite outings or trips including transportation in church-owned or personally-owned vehicles
*
Please select all that apply.
I Consent
I Do Not Consent
I give my consent to Immanuel Youth Ministries leaders, staff, and chaperones and/or qualified medical personnel to act on my behalf in securing and administering necessary emergency medical treatment for the above named child.
*
Please select all that apply.
I Consent
I Do Not Consent
I give my permission for my child to be shown in photos and videos. These photos and videos can be used to share about the trip or to promote Immanuel's ministries. *If you indicate “I do not consent,” your youth may still appear in group photos.
*
Please select all that apply.
I Consent
I Do Not Consent
By my signature, I certify that the information given in connection with this form is accurate. In consideration of Immanuel allowing the Participant to participate in youth ministries activities and events, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Immanuel, its pastors, directors, employees, volunteers and teachers from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth ministries activities and events.
*
Please enter today's date in the box below.
Medical Release Date
*
Submit
Description
Please fill out this form and update it if/when information changes.
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