Windsor Cornerstone Student release form
2018-2019 school year Parental permission, emergency medical and Release of Liability Form
Complete this form or print and return pdf
Student Name *
Your answer
DOB *
Date of Birth
MM
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DD
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YYYY
Address *
Your answer
School and Grade level *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Address (if different from student)
Your answer
Parent/Guardian Email address
Your answer
Parent/Guardian cell # *
Your answer
May we send you text updates *
Required
Photo Publication *
Throughout the year, at various events, photos are taken of our youth. These photos may be shared on church publications, our website and social media. Please let us know if we may publish untagged photos of your student.
Required
Emergency Contact Name *
*other than yourself, we will always contact you first
Your answer
Emergency Contact Phone *
Your answer
Medical Insurance Information
Unless a permission slip is specifically required for a specific event,
this Permission slip will cover all activities throughout the 2018-2019 school year.
Insurance Name *
if none type N/A in appropriate boxes
Your answer
Policy # *
Your answer
Group # *
Your answer
Doctor Name & Number *
Your answer
Please list any allergies or medications for your student
Your answer
Consent
(1) As a parent/guardian, I give my permission for the above minor (student) to attend Cornerstone Youth activities including regular group and any special activities for the 2018-2019 school year. I authorize treatment under the direction of any licensed physician of the above minor in the event of a medical emergency which in the opinion of the attending physician may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted after reasonable effort has been made to reach me by phone. I will not hold the church, or their staff, administration, or workers liable for any injury to or loss of possessions by the above minor during any activity either on church property or away, including regular meetings as well as special events.
(2) I also give permission for the above minor to ride in any vehicle driven by an approved adult chaperone while attending and participating in activities sponsored by Cornerstone Baptist Church. My student and I understand that seat belts shall be worn at all times during transportation
(3) I understand that in an effort to provide the best possible atmosphere at church sponsored events, youth are expected to cooperate with all advisors at all times. If my son or daughter fails to adhere to guidelines, I authorize the persons in charge of the event to take such action as they deem necessary and appropriate, which may include immediate return home at the Parent/Guardian’s expense.

Parent/Guardian Signature *
Entering your name is considered an electronic signature. You agree the information on this form is accurate.
Your answer
Date *
MM
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DD
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YYYY
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