Medical & Liabilities Release Form

For what area of ministry are you completing this form?*

Children's Ministry (Pre-K - grade 5)
Middle School Ministry (grades 6-8)
High School Ministry (grades 9-12)

Student's Name*

First Last

Student's Date of Birth*

Student's Grade*

Mother/Guardian's Name*

First Last

Cell Phone Number*

Email Address

Father/Guardian's Name*

First Last

Cell Phone Number*

Email Address

With whom does student live?*

Address Where Student Lives*

Street Address Address Line 2 City State ZIP Code

Alternative Phone Number (e.g. Home)

Emergency Contact Name (other than parent/guardian named above)*

First Last

Emergency Contact Phone Number*

Emergency Contact Relationship to Student*

Name of Healthcare Provider and/or Preferred Hospital*

Physician's Name

First Last

Healthcare Provider Address

Street Address Address Line 2 City State ZIP Code

Health History

Name and dosage of any medication student takes on a regular basis

Please list any special notes

By submitting this form, you confirm that you are the parent or guardian of the student for whom this form is completed, or are the student and are over age 18. By submitting this form, you are also agreeing to the following statements: In the unlikely event that I or my appointed emergency contact cannot be reached in an emergency while my student is with Bridges Community Church, I hereby give my permission to the physician selected by the Bridges Community Church supervisors to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my student as deemed necessary. I understand that all billings for services rendered will be sent to me as the parent/legal guardian and that I am responsible for the complete payment. In the unlikely event that my student is injured while participating in activities on or off the campus of Bridges Community Church or in route to such activities, my student and I relinquish all rights to recover damages for any and all injuries sustained by my student during or in route to activities. I acknowledge that if my student has to return home early for discipline violations, it will be at the parent/guardian’s expense. I also understand that photos and videos may be taken of my student while at Bridges Community Church events, which may be used by Bridges Community Church for future promotional purposes.

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