Student's Name *
Student's Name
Birthdate *
As of Fall this year
Parent / Guardian's Name *
Parent / Guardian's Name
Address *
Emergency Contact Name *
Emergency Contact Name
Contact Number *
Contact Number
Emergency Contact 2
Emergency Contact 2
Contact Number
Contact Number
Are there any conditions that might hinder your student from participating in activities?
If other please explain:
The Medical Release & Parent/Guardian Permission Form is good for the period of May 1, 2019 to May 1, 2020
Name of Student
Name of Student
…has my permission to attend all youth activities sponsored by Creekside Community Church, Alamo. Any activities from which your student should not participate must be submitted in writing to the Family Life Pastor prior to that event. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Creekside Community Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/We hereby release Creekside Community Church its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/We consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church, I/We agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/We affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. By filling out the below fields and checking off the box that you accept these terms, you are hereby giving your "signature" and parent/guardian permission.
Parent / Guardian Signature *
Parent / Guardian Signature
I agree to the terms listed above in this medical release form. *