Crossroads Student Ministry Permission/Medical Form
Crossroads Student Ministry Events for 2019-2020
Email address *
Student Name *
Your answer
Date of birth *
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Student age *
Your answer
Student sex *
Student grade *
Physical address *
Your answer
Parent/Guardian phone number *
Your answer
Parent email address *
Your answer
Student phone number *
Your answer
Student medical info: *
Required
Any necessary info regarding medical info above: (add N/A if nothing applies) *
Your answer
Health Insurance - Policy # - Group # (add N/A if nothing applies) *
Your answer
In case of medical emergency, I hereby give permission to the Physician selected by the leader in charge to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named on this form. I certify that my child is in good physical condition and is able to participate in the entire program, other than any activities listed as restricted above. I give Crossroads Community Church permission for my child to take part in all programming. I further agree to hold Crossroads Community Church and its agents harmless and to indemnify them against all losses, liabilities, suits, claims or expenses including fines, penalties and attorney's fees due to injury or alleged injury to my child incurred in connection with the operation of the conference or transportation thereto. I also assume the responsibility of any damages to the facility he/she is assigned to that was caused by him/her. I give Crossroads Community Church permission to use pictures and video of my child in multi-media presentations, advertisements and promotional material that is generated by or for Crossroads Community Church. I understand that Crossroads Community Church will use discretion and sound judgment in taking pictures and video, as well as using pictures and video of my child in the above stated manners. (PARENT/GUARDIAN-Please sign electronically below) *
Your answer
Code of Conduct: Students are expected to cooperate with all staff at all times and to participate in all scheduled activities they choose to attend. Possession and/or use of alcoholic beverages and/or any type of drugs and/or weapons are strictly prohibited. Failure to remain within these guidelines at any time is cause for the student's immediate return home at the parents/guardians expense. As the above listed minor's parent or legal guardian, I have read and agree to all of the above. (PARENT/GUARDIAN-Please sign electronically below) *
Your answer
Student signature regarding Code of Conduct (sign electronically below to indicate parent/guardian covered Code of Conduct with the student and student fully understands and agrees to comply) *
Your answer
Thank you for allowing your student to participate in Crossroads Student Ministry! We're excited to build relationships with them and help lead them into a lasting relationship with Jesus! For more information, contact us at youth@c3stockbridge.org *
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