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Brickhouse Permission & Medical Release Form
This form is effective June 1, 2018 through May 31, 2019
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Student #1 Name, Grade *
Student #2 Name, Grade
Student #3 Name, Grade
Student #4 Name, Grade
Parent or Guardian Name *
Street Address *
City, State, Zip *
Home Phone
Parent or Guardian Cell
Best time to contact you
I give permission for my above named student(s) to participate in all Brickhouse Student Ministry activities from June 1, 2018 to May 31, 2019. I hereby release Crossroads Community Church, its staff and sponsors, from responsibility and liability for any injury or illness that my child(ren) may sustain during these activities. In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me to consent to any X-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible. [Please type NAME and DATE below indicating signed consent] *
Emergency Contact Name
Emergency Contact Phone
Please list student allergies and medication below
Medical Insurance Carrier
Policy Number
Member's Name
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