Southwide Baptist Church Student Ministry 
Permission Form & Medical Release  

Please Print In Ink

Name:___________________________  Birthday:___________  Age:___ Grade:____  

Gender:_____ Email:_________________________ Address:____________________

Student Phone:_______________

Medical Insurance Company:___________________ Policy #:____________________

Family Doctor Name:__________________________ Doctor Phone:_______________ 

Parent/Guardian Name:________________________ Parent Phone:________________

Emergency Contact:________________________ Emergency Phone:_______________

Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff and/or sponsors should be aware, and what, if any action of protection is required on account thereof. 
________________________________________________________________________

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For your child’s safety and our knowledge, how does your student swim?
                                 ___ Good       ___Fair      ___Poor     ___ Non-swimmer

Does your child have any allergies? __ yes  ___ no If Yes Please List:________________ _______________________________________________

Does your child suffer from, or has experienced, or is being treated for: 
___Asthma		___ Seizures		___ Heart Trouble		___ Diabetes		
Date of last tetanus shot:__________________

                                              OVER
Please Read This Section Carefully with your child and Have Them Sign

I agree to follow these rules of conduct always and understand that if I fail to comply with these expectations I will be sent home at my parent or guardians expense and may forfeit future opportunities to participate:

	No possession or use of alcohol, drugs or tobacco products
	No fighting, weapons, fireworks, explosives or lighters
	No offensive or immodest clothing (Check Trip What To Bring List)
	No inappropriate music shall be brought on any trip
	No being in the rooms of the opposite sex without a chaperone 
	Participation in all group activities is expected
	Respect property, one another, staff, and leaders at all times
	Respect and comply with event schedules and rules
	No leaving an activity early without parent & youth leader permission

Student Signature:________________________ Print Name:______________________

Please Read This Carefully As The Legal Parent/ Guardian for the student listed above and sign. Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the student ministry leaders prior to that event.

I the legal guardian for the student named above give consent for that student to participate in all church student ministry activities that may include but are not limited to: horse back riding, cook outs, camping, boating, water skiing, swimming, basketball, roller-skating, rollerblading, Frisbee, games in the park, hiking, soccer, softball, baseball, flag football, downhill skiing, snowboarding, paint ball, volleyball, ping pong, biking, concerts, movies, shopping, Bible Studies, golfing, hayrides, rock climbing, eating out trips, banquets, visitation, worship times, and more. I understand there are inherent risks involved in any ministry or athletic type activity and I hereby release the church, it’s leaders, agents, pastors and volunteer workers from any and all liability for any injury, loss or damage to person, or property that may occur in the course of my child’s involvement. I also grant permission the leaders and sponsors of the student ministry activities to seek reasonable medical treatment for my child in the event of an emergency or injury. I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be responsible for any and all medical cost not covered by my health insurance provider. I understand that the leaders of the student ministry strive to make each and every activity as safe, fun, uplifting and educational as possible.  

Parent/Guardian Signature:_______________________________ Date:___________

Witness Signature:_______________________________________