Student VBS Permission Form

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Gender

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Gender

First Name

Last Name

Phone Number

Relationship to the Child(s)

Medical Insurance

Family Medical Insurance Carrier

Policy Number

List any diseases, physical or mental limitations, or medical conditions. (Asthma, Diabetes, Etc)

Allergies to Food, Medication or Insects

Please list Allergy details

Currently taking any prescriptions or non-prescription medicines

If yes, please list

Are there any other conditions or limitations we should be aware of?

Liability Release

I the undersigned do hereby declare that I am the parent or legal guardian of the above named student. As such I hereby grant permission for the above named student to attend and participate in Cowboys For Jesus Student Ministries and events and Cowboys for Jesus Church activities and events both on campus and off. This includes but is not limited to water sports.. I further acknowledge that Cowboys For Jesus Children Ministry leaders and volunteers will be temporary custodians of this student during the activities and events. I understand that if my student becomes unmanageable and refuses to obey Cowboys For Jesus rules or its leaders, I will be called to pick up my student.

I the undersigned parent or guardian of the above student do hereby release Cowboys For Jesus, their agents, officers, directors, and employees and volunteers from any and all liability for any accident, injury or harm to the above named student and or the students property which may resulting directly or indirectly from Student’s participation in any Cowboys For Jesus event. I as the parent or guardian do also hereby personally assume full responsibility and liabilities in connection with this student’s participation in this or any
event sponsored by or held at Cowboys For Jesus Christian Fellowship.

I also authorize the Cowboys For Jesus representative in charge of any event to consent on my behalf, in an emergency situation to any medical attention which he or she deems necessary for the student’s immediate health and well being. I also personally assume all responsibility and liability for all medical bills and expenses and also for claims for pain and suffering, civil damages, or any other
liability resulting directly or indirectly from the medical attention and also for any acts or damages caused by the behavior of the student. I understands and agree that this consent is given in advance of any specific diagnosis or treatment AND REMAINS IN EFFECT FOR ONE YEAR unless cancelled by me in writing. Furthermore, this consent is given to encourage the physician, dentist, or surgeon, and those persons who have temporary custody of the minor, to exercise his/their best judgment as to such diagnosis or medical, dental, or
surgical treatment as may be necessary.

Date Input

Signature

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