Student Release Form
The Destiny Center
This release form is effective for one year.
Email address *
Student(s) Name *
All students in household can be listed on same form.
Your answer
Emergency Contact (list 2) *
Please List: name, number & relationship to student(s)
Your answer
Allergies / Medical Conditions
if yes, please list & for which student.
Your answer
Please check any of the following that apply
Student 1
Please check any of the following that apply
Student 2 (if applies)
Please check any of the following that apply
Student 3 (if applies)
PLEASE READ CAREFULLY: I do hereby give permission for my student listed above, to participate in all church activities (both on and off site). I release The Destiny Center from any liability while as a passenger in a church van or personal vehicle and any association with all activities. Photocopies of this document shall have the same force and effect as the original. I do authorize an adult leader of the activity as agent for me, to consent to any x-ray examination, medical, dental or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, dentist (as appropriate), licensed to practice under the laws of the state (country) where services are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible. I understand my child may be transported in a church vehicle and that safety rules will be followed. If a discipline problem is deemed serious enough by the supervising adults, my child/youth will be sent home at parent's expense. I have read the permission form above and am in full and complete agreement. Please Sign. *
Your answer
Date of Form Completion *
A copy of your responses will be emailed to the address you provided.
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