The Church of the Master

Medical Release & Permission Form

Activity attending: _____________________________ Effective date: _________

Please print in ink:

Name ______________________________________     Age ______

Year in school __________    Birthday _____________

Address ____________________________________________________________

City, State, Zip _______________________________________________________

Phone where you can be reached ____________________________________

Cell ____________________________________

Mother’s name ____________________________________

Home/Work Phone ____________________________________

Father’s name ____________________________________

Home/Work Phone ____________________________________

Emergency contact ____________________________________

Home/ Work Phone ____________________________________

For your information, we expect each student to conform to these rules of conduct.

No possession or use of alcohol, drugs, or tobacco

               No students can drive

               No fighting, weapons, fireworks, lighters, or explosives

               No offensive or immodest clothing

               Participation with the group is expected

               Respect property

               Respect one another, staff, and adult leaders

Students who fail to comply with these expectations may be sent home with their parents.

I, the student, have read the rules of conduct, and permission to participate in youth group activities. I agree to these rules.

Student signature: _____________________________ Date: _________

I give permission for my child to participate in this youth activity. This consent form gives permission to seek whatever medical attention is deemed necessary by a licensed physician, and releases the Church and its staff of any liability against personal losses of named child. I also agree to bring my child home should they become ill or if deemed necessary by the youth advisors.

Parent signature: _____________________________ Date: _________