Christ Chapel Medical Release Form/Permission Slip
Christ Chapel Warner Robins
2288 Moody Rd.
Warner Robins, GA 31088
(478) 922-0161
Email address *
Student / Leader Information:
Please fill out all lines
Full Name: *
Your answer
Address *
Your answer
City, State, Zip *
Your answer
Phone # (please indicate cell or home) *
Your answer
Student D.O.B. *
Your answer
Emergency contact info. (name, phone# & relation) *
Your answer
Medical Information:
Please fill out all areas
Physician's name & phone # *
Your answer
Health Insurance Co. & Policy # *
Your answer
Known Allergies (Food allergies too) *
Your answer
Current or Chronic Conditions *
Your answer
Medications now taking *
Your answer
Are immunizations Current? *
Is Tetanus current? *
Is there anything that would prevent or restrict student's participation? *
If yes, please explain:
Your answer
For your student's safety and our knowledge, is your student a -- *
For your information, we expect each student to conform to these rules or conduct:
*No possession or use of alcohol, drugs or tobacco
*No students under the age of 18 can drive to events outside of the Middle GA area without written Permission
*No fighting, No weapons, No fireworks, No lighter, or explosives
*No boys in girls' sleeping quarters & No girls in boys' sleeping quarters
*Any irresponsible behavior is prohibited
*Participation with group is always expected
*Respect property, one another, staff & adult leaders
*Respect & comply with event rules and schedules


I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in Christ Chapel student activities. I agree to abide by the stated personal limitations and code of conduct. (Digital Signature of Student Below & Date)
Your answer
Activity Permission Slip
When Christ Chapel has an organized youth activity, as parent/legal guardian, I give the above mentioned child permission to participate in all activities, except for any restrictions listed above.
Medical & Liability Release
In the event of sickness, injury or some medical emergency, I/we request that my/our child receive any medical attention to treatment deemed necessary. Therefore, I/we the parent(s)/guardian(s) give permission and hold harmless to any hospital, doctor, and/or health care provider to transport, treat, and/or admit for care my/our child. In the event that I/we are not present at the time of the emergency, my/our child's care has been entrusted to the staff and designated adult leader Christ Chapel Warner Robins while attending any youth function or activity both on and off church grounds. I/we also acknowledge that we will be ultimately responsible for the cost of any medical care, should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance company provided above is accurate at this date and will , to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our expense should they become ill or if deemed necessary by the student ministries staff member.

I/we also release Christ Chapel, it's agents, assigns, staff, employees as well as volunteer workers form any liability whatsoever arising out of property damage or loss as well as injury, sickness or death which may be sustained by my/our child's the result of any participation in church sponsored or related function or activities.

Name & Signature of Parent(s)/Guardian(s)-- (Digital Signature Below & Date)
Your answer
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