Unleashed Medical Release and Participation forms
These are the forms that we must receive in order for your student to participate in any of our Unleashed youth activities. Please complete all 4 sections.
The forms we use for Unleashed Youth Ministries require a signature. By checking the consent box below, you are consenting to the use of this "electronic signature" in lieu of an original signature on paper for all parts in this document that request your consent. You have the right to choose to sign a paper copy instead. By checking the consent box, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. *
Student's Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
School *
Your answer
Grade *
Track if applicable
Your answer
Parents Name *
Your answer
Parent Email *
Your answer
Address *
Your answer
Phone number *
Your answer
Emergency Contact /phone number *
Your answer
Medical Insurance Co. & policy number *
Your answer
Primary Physician & Office number *
Your answer
Dentist & Office number *
Your answer
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