Grace Bible Church Student Participation & Annual Release Form (6th-12th Grade; July 31, 2019 - August 30, 2020)
Grace Bible Church
6023 Dutton Place
Newfane, NY 14108
(716)778-9081

Contact: Pastor Matt Weir
C: (312)420-5665
E: mweir@gbcnewfane.com
Email address *
RELEASE FORM
Please read and sign the annual release form below.
Name of minor: *
Your answer
I/We give consent for (name of minor above) to attend any Student Ministries events being sponsored by Grace Bible Church from July 31, 2019 through August 30, 2020. In the event that he or she is injured while under the care of Grace Bible Church and its representatives and requires the attention of a doctor, I hereby consent to and will be responsible for any reasonable medical treatment as deemed necessary by a licensed physician. I/We further agree to hold the licensed physician, the medical facility, Grace Bible Church and its representatives free and harmless of any claims, demands or suits for damages rising from the authorization and provision of such medical treatment. I/We understand the nature of the events and do hereby release Grace Bible Church and its representatives from any liability due to accident or injury incurred by my child. *
Required
Type in your full legal name. *
Your answer
Type in today's date. *
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CONTACT INFORMATION
Every possible safety precaution will be taken by those in charge and every possible attempt will be made to contact the parent or guardian immediately in the event of injury or other emergency.
Name of Parent/Guardian *
Your answer
Address *
Your answer
City *
Your answer
Phone (Cell) *
Your answer
Phone (Other) *
Your answer
Email *
Your answer
Minor's DOB *
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Grade of Minor *
Age of Minor *
Your answer
Minor's Gender *
Required
Special Concerns, Medications or Allergies (including food allergies/sensitivities) *
Your answer
Family Doctor *
Your answer
Family Doctor's Phone Number *
Your answer
Insurance Company *
Your answer
Name of Policy Holder *
Your answer
Group/Policy # *
Your answer
Emergency Contact if Parent/Guardian unable to be reached *
Your answer
Emergency Contact's Phone *
Your answer
Emergency Contact's Relationship to Minor *
Your answer
Home Church (if applicable)
Your answer
People authorized to drop off/pick up my child (other than listed above) *
Your answer
My child has permission to walk home from church *
My child has permission to ride home with a leader *
Grace Bible Church has my permission to use pictures of my child in church brochures, posters, outreach material, church web pages, etc. *
SIGNATURE *
Required
Type in your full legal name. *
Your answer
Type in today's date. *
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