Child/Student Medical Release and Permission Form

required = Required Fields

Child/Student Medical Release & Permission Form

For your information, we expect each child/student to conform to these rules of conduct
  • No possession or use of alcohol, drugs, or tobacco
  • No fighting, weapons, fireworks, lighters, or explosives
  • No offensive or immodest clothing
  • Participation with the group is expected
  • Respect property, one another, staff, and adult leaders
  • Respect and comply with event schedules
  • No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
Parents will be called to take home a child/student who fails to comply with these expectations or will be sent home at the parents’ expense.

     I, the child/student, understand and agree to abide by the stated personal limitations and code of conduct.

Activities may include, but are not limited to: cookouts, basketball, skiing, roller-skating, games in the park, soccer, Awana games, kickball, Bible studies, quizzing, Grand Prix, carnivals, volleyball, softball, baseball, bowling, and miniature golf.  Note: If you desire to limit your child’s/student’s participation in any event, please submit your wishes in writing to the church prior to that event.

has my permission to attend all student or children’s ministry activities sponsored by Southgate Baptist Church (hereinafter the “Church”) during the school year dated above.

Declaration of Intent

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church, its staff, and volunteers of any liability against personal losses of named child.

I/We the undersigned have legal custody of the student/child 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 the Church, its pastors employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that my occur during the course of my/our child’s involvement.

In the event that he/she is injured and required 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 also 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 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 children home at my/our own expense should they become ill or if deemed necessary by student ministries staff member.

Describe below the details regarding the nature and severity of any physical and/or psychological ailment, illness, disability, or condition to which your child/student is subject and of which the staff should be aware, and what, if any action or protection is required on account thereof. Also include names of medications and dosages that must be taken.

Click the following areas of concern for this student.
For your child’s safety and our knowledge, is your child/student a:

Does your child have allergies to:

Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:

Does your child wear