Upper Room Student Ministry Release Form 2020/2021

This medical release form is for all non-retreat/camp events from Fall 2020 through Fall 2021. Please fill out all required fields before hitting submit.
Parent/Guardian Information

 
 
 
 
 
 
 
Student Information

 
 
 
 
 
Release of Liability

I hereby grant permission for my child to participate in the activities of the DeWitt Christian Church Student Ministries.  I further give permission for DeWitt Christian Church to take my child off campus for scheduled activities. I understand that my child participates in these activities at their own risk and that the DeWitt Christian Church and its adult supervisors are not liable for any injury personal or otherwise to my child or caused by my child.  Should any problems arise concerning the behavior of my child that would require them to return home prior to the end of the activity, I will pay for his or her return or come pick my child up.  I further understand that DeWitt Christian Church and its adult supervisors are not liable for any items that may become lost or stolen.
 
*By entering my name in the box above, I am providing my digital signature for this field.
Medical Release

 
 
Please select one option.

I authorize the treatment, by a qualified and licensed medical doctor, of the minor listed above in the event of any medical emergency, which, in the opinion of the attending physician, is necessary and I/we cannot be reached after reasonable effort has been made to secure my personal consent.


I certify that my child is covered by adequate accident insurance.  My consent and signature is given below.  I have read and agree to the information given on this entire form.

 
*By entering my name in the box above, I am providing my digital signature for this field.
Photo and Video Release


I recognize that the DeWitt Christian Church uses photographs and video images of events in their publicity materials such as the church website, social media, and printed promotional material and I hereby grant permission for photo and/or video images of my child to be taken and used for such purposes.

 
*By entering my name in the box above, I am providing my digital signature for this field.

Description

This medical release form is for all non-retreat/camp events from Fall 2020 through Fall 2021. Please fill out all required fields before hitting submit.