Student Ministry Medical & Photo Release Form

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Student Information

First Name *

Last Name *

Date of Birth *

MM / DD / YYYY

Age *

Gender *

Male
Female

School Name *

Grade *

*RSM is for 6th through 12th grades.

Student Phone Number

Street Address *

Other Address (optional)

City *

Zip / Post Code *

Parent / Guardian Information

Parent / Guardian Name(s) *

Please also define relationship to the student.

Parent / Guardian Phone Number *

Parent / Guardian Work Number (optional)

Parent / Guardian Email *

Medical Information

If possible, please provide a copy of your insurance card to the Director of Student Ministry.

Name of Insurance Company *

Policy Number *

Medical Issues and/or Allergies *

Current Medications *

Other Information

Parent / Guardian Permissions

I hereby give my permission for my student to be photographed or videoed for the Refton Student Ministry website or other student ministry promotions. *

Parent / Guardian Medical Permission *

I hereby give my permission for my student to receive emergency medical and/or dental treatment from a physician in the event of illness or injury. I will not hold the staff, counselors or the Refton Brethren In Christ Church responsible for any incident or accident that occurs to my child resulting from reasonable and prudent activities or counselor action. I am aware that by clicking "I Agree" I am giving my full consent.

I Agree