Student Ministry Medical & Photo Release Form

Fields marked with an * are required

Student Information


*RSM is for 6th through 12th grades.

Parent / Guardian Information

Please also define relationship to the student.

Medical Information

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

Parent / Guardian Permissions

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.