Zion Reformed Church Youth Ministry Release Form September 2021

Student Information

Student Name

Student Email

This address will receive a confirmation email

Student Cell Phone or method of texting

Student Address

Gender

Male Female Other

Birthdate

Grade

School Name & District

Membership of Zion/Profession of Faith

Baptized Member of Zion Personally Professed Faith/Confessing Member Attend Zion but not a member Member of another church Attend another church Don't attend any other church Other

Parent/Guardian 1

Full Name

(Cell) Phone

This address will receive a confirmation email

Physical Address (if different from Student Address)

Mailing Address (if different from Physical Address)

Parent/Guardian 2

Full Name

(Cell) Phone

This address will receive a confirmation email

Address (if different from Student Address or Parent/Guardian 1)

Parent/Guardian 3 (if applicable)

Full Name

(Cell) Phone

This address will receive a confirmation email

Address (if different from other addresses)

Emergency Contact Person (Other than Parent/Guardian)

Name

Relationship to Student or Guardian

(Cell) Phone

Medical Information

Insurance Company

Insurance Policy Number

Group Number

Student's Physician

Physician's Phone Number

Childhood Immunizations are current?

Yes No

COVID Vaccine Received

Yes No I'd prefer not to answer

Your Student Can Receive Over-the-Counter Medications from adult leaders (such as Tylenol, Benadryl, Advil, etc.)

Yes No

Is your child in general good health and is able to participate in all activities?

Yes No

If No, please explain:

Any Food Allergies?

Yes No

If Yes, List Any Food Allergies/Dietary Restrictions

Any Other Allergies?

Yes No

If Yes, List Any Other Allergies

Any Pre-existing Medical Conditions (ADHD, Depression, Anxiety, Autism Spectrum, Downs Syndrome, Bi-Polar, etc.)?

Yes No

If Yes, List Any Pre-existing Medical Conditions (ADHD, Depression, Anxiety, Autism Spectrum, Downs Syndrome, etc.)

Does Your Child Take Any Prescription Medication?

Yes No

If Yes, List Any Medications

Any other special conditions we should be aware of?

Yes No

If Yes, list any other special conditions we should be aware of

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.

Today's Date

*Electronic Signature

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

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

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

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