Church Student Ministry Medical Release Form

Obtain parental medical consent so students can safely take part in youth ministry retreats or mission trips.

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Student's Name

First Name

Last Name

Current Grade

School Student Attends

Student's Email

Student's Cell Number

Student's Gender

Male Female Other

Address

Street Address

City

State / Province

ZIP / Postal Code

Parent/Guardian Name

First Name

Last Name

Phone Number

Email

Emergency Contact

First Name

Last Name

Phone Number

Insurance Company

Claims To Be Mailed To

Policy or ID Number

Family Physician

Phone Number

Medications Currently Taking (list all, even vitamins)

List Allergies

Date of Last Tetanus Shot

Permission to Give

I give permission for my child to receive emergency medical treatment

Special Instructions Regarding Student

Student's Name Here

Parent/Guardian Signature

Sign here

Date

Student Signature

Sign here

Date

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