Medical Release Form For Minors


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
Parent/Guardian Signature and Date
This permission remains in effect until revoked in writing by parent/guardian.


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