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Crossbridge United Release Form
The following release form will cover Crossbridge United activities from October 1st, 2018 until September 30th, 2019.
Student's Legal Name: *
Your answer
Grade: *
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Birthdate ( MM/DD/YYYY): *
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Address: *
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School: *
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Student Cell Phone Number:
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Gender: *
Parent/Guardian Name: *
Your answer
Parent/Guardian Email:
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Parent/Guardian Cell Phone Number: *
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Parent/Guardian Home Phone:
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Emergency Contact (Other than parent/guardian): *
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Emergency Contact Phone Number: *
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Student's Medical Information:
Insurance Company: *
Your answer
Policy Holder: *
Your answer
Policy Number: *
Your answer
Allergies:
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Medical Conditions:
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Current Medications:
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Note: All medications (prescription and non prescription) must be checked in to a youth leader at each event. The leader will administer all medications according to parents and/or doctor's instructions. List any instructions for the administering of the student's medication:
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Other restrictions or medical concerns:
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Student Behavior Expectations and Release
For your information, we expect each student to conform to these rules of conduct:
-No possession or use of alcohol, drugs, or tobacco.
-No fighting, weapons, fireworks, lighters, or explosives.
-No offensive or immodest clothing.
-No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
-Participation with the group is expected.
-Respect property.
-Respect one another, staff, and adult leaders.
-Respect and comply with event schedules and rules.
Students who continually fail to comply with these expectations may be sent home from an event at their parents’ expense.
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Statement of Release
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Crossbridge Community Church and its staff of any liability against personal losses of named student. This consent form also gives authority to Crossbridge Community Church and its staff to provide necessary transportation for named student using vehicles owned by Crossbridge Community Church of the Nazarene and/or designated privately owned vehicles. In addition, this consent form grants Crossbridge Community Church the right to reproduce and use photographs and videos taken at events sponsored by them either wholly or in part, and the unrestricted use thereof in whatever manner they deem for website, brochure, advertising, or other purposes. In signing this consent form, I also give permission for Crossbridge Community Church, its staff, and volunteer workers to text and/or call my student about upcoming events or gatherings related to Crossbridge Community Church.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to participate in events being organized by Crossbridge Community Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release Crossbridge Community Church, its staff, sponsors, and other volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our student’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Crossbridge Community Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. I/we agree to make a written request, through letter, email, or text, if I/we do not want our student to receive texts or calls about Crossbridge Community Church events.

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Parents/Guardian's Electronic Signature *
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