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Student First Name
Student Last Name
Parent 1 First Name
Parent 1 Last Name
Parent 2 First Name
Parent 2 Last Name
Emergency Phone Number
Alternate Emergency Phone Number
Health Insurance Company
Health Insurance Policy Number
Allergies
Current Medication(s)
Other Pertinent Information
In the event of an emergency or non-emergency situation requiring medical treatment, I, the undersigned parent, hereby grant permission for any and all medical and/or dental treatment to be administered to my child named above, in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, administration of first aid, use of an ambulance, and administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel.
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Yes
No
For all student events that include riding in the church van, I give my permission for my student to travel with 3BC staff and participate in all events for 2023/2024.
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Yes
No
Our church uses photos and videos of our students for communication purposes. Signing this release grants us permission to use your child's image for these purposes.
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Yes
No
I acknowledge I am the parent (or guardian) of the named student(s) and have read and agree to the aforementioned statements and give permission for my student(s) to participate in all 2023/2024 events.
E-Signature of Parent
Date Signed (MM/DD/YYYY)
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