Student Medical Release Form 2025/2026

Your name *

Email address *

Current Grade *

Pre-Teen (4th-5th)

Jr. High (6th-8th)

High School (9th-12th)

Medical Form

I, the undersigned parent/legal guardian, do hereby grant permission for for the child listed above, to participate in various activities sponsored by Pendleton Christian Church from August 1, 2024- August 1, 2025. I am aware that this covers activities at and away from the Church Ministry sponsored premises. In order that my child may receive adequate medical treatment from volunteer medical staff involved in the ministry or from the medical staff of hospitals, I hereby consent to medical treatment of my child, should he or she sustain injury or illness while involved in a youth group activity. I hereby release the Church Staff, volunteer staff, event staff, and various agencies providing youth events from all debts, judgments, or suits of any kind that may arise as a result of the applicant’s participation in church sponsored programs. I further acknowledge and understand that while participating in church activities there is a risk for injury and/or illness. Payment of any medical expenses will be paid by myself and/or my insurance company.

Parents Signature *

Student's Height *

eg. 5'7"

Student's Weight *

eg. 125lbs

Student's Date of Birth *

Insurance Company *

Policy Number *

Group Number *

Subscriber's Date of Birth *

Parents or Guardians

First and Last Name

Parents or Guardians Daytime Phone *

Parents or Guardians Evening Phone *

Video/Photographs Concent *

Do you consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the youth during the activities attended by them to be used, distributed or shown as the church deems appropriate?

Yes

Have you read the items above and understand the conditions of this medical release form? *

I have read and fully understand this form.

Parent/Guardian Name *

Today's Date *

Parent/Legal Guardian Initials *

Consent and Release *

By signing this statement, I am giving my consent for the above named student to participate in all Church Ministry sanctioned activities during the church year as set forth above, whether located at the church or within Madison, Marion and Hamilton Counties, Indiana and if necessary, consent to said child being transported by church staff or their designated volunteers to, from, and during said activities by rental or private vehicles. I understand that a separate consent form will be provided to me before my child will be permitted to participate in or be transported to an out of county activity or any overnight activities regardless of location. When I drop my child off at a Church Ministry sanctioned activity or allow my child to be transported to such an event, I am granting my consent for my child to fully participate therein unless otherwise directed by me in writing. Finally I understand that all reasonable safety precautions will be taken at all times by Pendleton Christian Church and its agents during the activities and events that the youth will be invited to participate in. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree, therefore, not to hold Pendleton Christian Church, its leaders, employees and volunteer staff liable for damages, losses, diseases or injuries incurred by the youth. I the undersigned have carefully read the foregoing consent and release and are signing of our own free act or deed*

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