Medical Release Form For Minors printable pdf download

Medical Release Form for Minors

To be printed out and signed.

I (we) the undersigned parent(s) of __________________________________________, a minor, do hereby give

permission for my child to attend St. Peter’s in the Woods Vacation Bible School and in the event of an accident or

illness, to receive emergency medical treatment as deemed necessary by a licensed physician. I also agree by execution

of this document to release Parish Youth Ministries, the staff, St. Peter’s in the Woods, and all others acting for or on

behalf of St. Peter’s in the Woods from all liability whatsoever, for personal injury, or damages to property, real or

personal, caused by, or arising out of activities sponsored by Parish Youth Ministries.

Printed Name of Parent/Guardian

Signature of Parent/Guardian

Contact Numbers: home _______________________________ cell_____________________________________

Insurance company and policy number:______________________________________________________________

Emergency Contact Name:___________________________________________________

Emergency Contact Numbers: home ___________________________ cell_____________________________

Please list any allergies or medical concerns below:

St. Peter’s in the Woods Permission to Use Images, Sound and Video Release Form

I hereby grant permission for St. Peter’s in the Woods Episcopal Church and the Diocese of Virginia to record

sounds, images or video of my child(ren) ________________________________________________ (name)

________________________________________________ (name)

I also give permission for St. Peter’s in the Woods Episcopal Church and the Diocese of Virginia, at their sole

discretion, to use these images in church publications, marketing and promotional material, and on Web sites

owned by St. Peter’s in the Woods Episcopal Church or the Diocese of Virginia.

I choose to OPT-OUT for myself/child being used in St. Peter’s in the Woods printed materials, webpages,

and other audio or video presentations.

_________________________________________

Parent/Guardian Signature and Date

This permission remains in effect until revoked in writing by parent/guardian.

Medical Release Form For Minors