Zion Reformed Church Youth Ministry Release Form September 2021 - August 2022

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Student Information

 
 
 
 
 
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Parent/Guardian 1

 
 
 
 
 
 
 
Parent/Guardian 2

 
 
 
 
 
Parent/Guardian 3 (if applicable)

 
 
 
 
 
Emergency Contact Person (Other than Parent/Guardian)

 
 
 
Medical Information

 
 
 
 
 
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Release of Liability & Media Release

By signing this form, I hereby certify that the above information is correct and grant permission for the use of photographs and videos including my child for use on social media, Zion’s website or for in house publicity; for my child to be transported to and from off campus activities; for the release of medical records in case of illness or injury; and for the student named herein to engage in all activities except as noted by me. I also give my permission to the physician selected by Zion to secure proper medical treatment for the student named herein in case of illness or injury. If any changes on this form occur before September 1, 2021, I agree to notify Zion Reformed Church and it's staff of these changes.

 
 
*By entering my name in the box above, I am providing my digital signature for this field.

Description

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