FPCWF Student Ministry Release Form
FPC must have a copy of your medical insurance card in order for students to participate on trips. Please take a photo of your card and forward to youth@myfirstpres.org.
Email address *
Student Name (First & Last) *
Your answer
Student Grade (as of Fall 2018) *
This child tentatively plans to attend:
Emergency Contact *
Your answer
Emergency Contact Phone Number *
Your answer
Known Allergies or Medical Concerns: *
Your answer
Medical Release: I/we, the undersigned parent(s) or legal guardian of the minor listed, do hereby authorize in an emergent or non-emergent situation any administration of aid or treatment by any physician or dentist licensed by the state and hospital service that may be rendered to said minor under the general, specific or special consent of the temporary custodian of the minor, whether such diagnosis or treatment is rendered at the offices of the physician or dentist to call in any necessary consultants, in his/their discretion. I fully understand that I will pay for all transportation, emergency room fees, and doctor bills should they be deemed necessary in an emergency situation. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgement as to the requirements of treatment. *
Photography & Video Release: I grant First Presbyterian Church (FPC) the right to take photographs or videos of me/my family in connection with FPC events. I authorize FPC to copyright, use and publish the same in print and/or electronically. I agree that FPC may use such photographs and videos with or without names and for any lawful purpose, including for examples such as publicity, illustration, advertising, and web content. *
For questions, email us at youth@myfirstpres.org, or call the church office at (940)767-2547.
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