Student Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact 1 *

First Name

Last Name

Emergency Contact 1 Home Phone *

(###)

###

####

Emergency Contact 1 Work Phone *

(###)

###

####

Emergency Contact 2 *

First Name

Last Name

Emergency Contact 2 Home Phone *

(###)

###

####

Emergency Contact 2 Work Phone *

(###)

###

####

Primary Care Physician Phone *

(###)

###

####

Check the appropriate information *

Asthma

Sinusitis

Bronchitis

Kidney Trouble

Diabetes

Heat/Cold Injuries

Heart Trouble

Dizziness

Stomach Problems

Hay Fever

Other

None

Allergies *

Food

Drugs

Insects

Vegetation

None

Other

Childhood Diseases *

Chicken Pox

Measles

Mumps

Whooping Cough

Other

None

Parent/Legal Guardian Signature *

PERMISSION FOR TREATMENT In the event that I/we the undersigned parent(s) or guardian(s) cannot be reached, I/we do hereby authorize adult workers for the youth group of The Quest Church, Royse City, TX as agent(s) for the student name above, to consent to any examinations, x-rays, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is rendered under the general or special supervision of any physician, surgeon, anesthesiologist, dentist, or other qualified medical personnel licensed under the provinces of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. RELEASE OF LIABILITY I/We, the undersigned, do hereby release, remise and forever discharge The Quest Church and all adult workers for the TeenQuest Ministry of The Quest Church from any and all claims, demands, actions or cause of action, past, present, or future arising out of any damage or injury while participating in a church sponsored trip or event. PHOTO/AUDIO/WEB RELEASE Further, I/We consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the participant during their participation in any activity, event, or trip to be used, distributed, or shown as the church sees fit including but not exclusive to: slide shows, church web site, print media and local newspapers. (When used in the public realm identifying information will be used responsibly e.g. names will not be attached to specific pictures on the church web site).

First Name

Last Name

Parent/Legal Guardian Signature Date *

PARENTS ARE RESPONSIBLE FOR UPDATING THIS INFORMATION SHOULD CHANGES OCCUR. This is valid through December 31, 2024.

MM

DD

YYYY