Pine Run EMC | Student Release Form
Email address *
Name of Parent/Guardian: *
Your answer
Phone Number: *
Your answer
Please contact me by: *
Required
Emergency Contact for Student: *
Your answer
Emergency Contact Phone: *
Your answer
Student's Name: *
Your answer
Student's Grade / Age: *
Your answer
Student's Address: *
Your answer
Student's Email: *
Your answer
Known foods, contact type and/or medication allergies: *
Your answer
Known medical conditions and/or limitations: *
Your answer
As the Parent / Guardian of the above-named student, I give permission for the above-named student to attend and participate in all official Pine Run EMC events. *
Required
As the Parent / Guardian of the above-named student, I understand that Pine Run EMC carries no medical or hospitalization coverage for participants in activities, ministries, services or events sponsored by Pine Run EMC. Furthermore, I will not hold the Pine Run EMC staff, volunteers, or agents liable for any accident that the above-named student may incur while traveling to/from or attending activities, gatherings or events sponsored by Pine Run EMC. In the instance(s) that the above-named student becomes injured/ill while at a Pine Run EMC sponsored activity or event, I hereby authorize the staff, volunteers, and agents of Pine Run EMC to use their judgment in providing first aid, medical assistance, and/or care, and/or to secure medical aid and ambulance service transportation to a medical facility for further treatment and care. To the best of my knowledge, the above-named student has no medical, physical, emotional, mental or other condition that would make it inadvisable for full participation. (Please note any information pertinent to caring for your child in the area provided above.) *
Required
As the Parent / Guardian of the above-named student, I give permission that the approved staff or volunteers of Pine Run EMC can transport the above-named student, to and from any official events / meetings of Pine Run EMC. *
Required
As the Parent / Guardian of the above-named student, I acknowledge that on occasion, Pine Run EMC takes photographs or makes audio/visual recordings of students involved in sponsored activities. Such media may be published to the public through digital or printed media. I consent to the use of such audio/visual. *
Required
As the Parent / Guardian of the above-named student, I understand that this form is effective from the date signed or until revoked in writing by the signee. *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy