Fusion for teens release/permission forms
Cedar Creek Church Student Ministry Release Form (Good for all Fusion events)
Cut and paste, print, fill out and give to appropriate person
Name______________________________________ Birthday______ /_______ /_______ Male Female
Parent/Guardian_________________________Phone (H)_______________Phone (W)_____________Phone (Cell)____________
Address_______________________________________________City ___________________ State_______ Zip______________
Second Parent__________________________Phone (H)________________Phone (W)_____________Phone (Cell)____________
Alt. Emergency Contact___________________Phone (H)_______________Phone (W)________________Phone (Cell)_________
Student email address __________________________________________Parent email address_____________________________
Medical insurance carrier _______________________________________Policy or group #________________________________
Carrier address________________________________________________Name of insured person__________________________
Name of family physician__________________________________________________Phone _____________________________
Health History (Check. Give approximate dates) Allergies (dates not needed)
_______Frequent Ear Infections _______Diabetes _______Bleeding Disorders _____Hay Fever
______Heart Defect/Disease ______Asthma _______Mononucleosis _____Poison Ivy
______Seizures ______ADHD _______Downs Syn. _____Penicillin
______Chicken Pox ______Measles _______Mumps _____Insect Stings
_____Drugs(specify)_________________
Chronic or recurring illness or medical condition___________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________
Dietary restrictions__________________________________________________________________________________________
Current medications (List both prescription, OTC & herbal)
Medication name: _______________________________ Dosage _________________Reason for taking_____________________
Medication name: _______________________________ Dosage _________________Reason for taking_____________________
Blood type (if known)_____________ Are all immunizations current? (MMR, tetanus, hepatitus) Yes ? No?
Describe your swimming ability: Beginner ? Intermediate ? Advanced ?
Any other information you feel the leaders should know in advance about your healtht.____________________________________
__________________________________________________________________________________________________________
I(We) acknowledge that my child’s participation in the Cedar Creek Church youth program is voluntary and
may require involvement in activities that require traveling or physical exertion. Such activities may include,
but are not limited to: outings, athletic games, local excursions, and meetings. I (We) acknowledge that my
child’s participation in any Cedar Creek youth activity presents risks that my child may suffer property
damage, bodily injury, or death. Therefore, in consideration of my child’s being allowed to participate in the
Cedar Creek youth program activities, I (we) agree to the following:
Cedar Creek Church is not responsible for the loss or theft of personal belongings.
Misconduct may result in transportation home from an activity at parents’ expense. A student dismissed for a
disciplinary reason will not receive a refund of the activity fee.
I hereby take the following action for my child, myself, my executors, administrators, heir, next of kin, successors
and assigns: A) I waive, release, and discharge from any and all claims or liabilities for death or personal injury
damages of any kind, which arise out of or relate to my child’s participation in Cedar Creek’s Youth activities,
the following person, or entities: Cedar Creek Church, it’s Senior Pastor, youth pastor and any
volunteers and representatives of any of the above except in the case of gross negligence on the part of Cedar Creek, Cedar Creek staff or Cedar Creek volunteers.
I indemnify and hold harmless the person or entities mentioned above from any claims made or liabilities assessed
against them as a result of my child’s actions.
The undersigned _______________(parent/guardian), the parent and natural guardian or legal guardian of
___________________ (minor’s name) hereby executes this document for and on behalf of the minor named
herein. I agree to indemnify and hold harmless the person or entities mentioned above for any claims or liabilities
assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the
minor in the execution of the Waiver and Release.
I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care
facility to treat the minor named herein for the purpose of attempting to treat or relieve any injury received by said
minor. I authorize any such Medical Provider to perform all procedures deemed medically advisable in attempting
to treat or relieve any such injuries. I consent to the administration of anesthesia as deemed advisable. I realize and
appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I
assume any such risk for and on behalf of myself and said minor. I understand that attempts will be made to contact
me in the most expeditious way possible. Permission is also granted toCedar Creek Church representative to provide
the needed emergency treatment to the student prior to his admission to a medical facility.
I hereby agree to the all the above Cedar Creek Church Student Ministry Waiver and Release Form Liability conditions.
Child’s Name___________________________________________________________________________
Parent(s)/Guardian Signature______________________________________________________________
Parent(s)/Guardian Phone ________________________________________________________________
Date_________________________________
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PERMISSION FORM (Must be filled out for each event)
Cut and paste, print, fill out and give to appropriate person
My child has permission to attend_________________________________________ on _____________________________.
. Note: If it is your desire to limit your child’s participation in any event, please submit your wishes in writing to
Cedar Creek Church prior to that event.
Parent(s)/guardian Signature ___________________________________________________ Date_________________
Student’s Signature___________________________________________________________ Date_________________