Youth Medical/Travel Release Form

Parent/Legal Guardian 1 First Name

Parent/Legal Guardian 1 Last Name

Parent/Legal Guardian 2 First Name

Parent/Legal Guardian 2 Last Name

Child First Name

Child Last Name

Parent/Legal Guardian 1 Phone Number

Parent/Legal Guardian 2 Phone Number

Child Phone Number

Parent/Legal Guardian 1 Email

Parent/Legal Guardian 2 Email

Child Grade

Child Birth Date

Child’s Main Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Child Allergies

Child Medical Conditions/ Special Medical Information

Child Current Medications

I authorize AVCC adult leaders to provide appropriate over-the-counter medications according to package directions when reasonably necessary.

Yes

Child’s Physician Name

Physician Phone Number

Medical Insurance Company

Insurance Policy Number

I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of Ashley Valley Calvary Chapel (AVCC), both on and off church grounds, including the necessary transportation to and from these events and activities. Permission is granted for AVCC staff or designated adult leaders to obtain reasonably necessary emergency or urgent medical care for my child when, in their reasonable judgment, medical attention is needed and I cannot be contacted in sufficient time to provide authorization. This authorization includes examination, diagnostic procedures, treatment, hospital care, and emergency medical transportation as deemed reasonably necessary by licensed medical personnel. AVCC will make reasonable efforts to contact a parent or legal guardian as soon as practicable.
I further agree not to hold Ashley Valley Calvary Chapel or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless AVCC for all claims made and liabilities assessed against them as a result of any event or activity. I release AVCC and all medical providers from liability in acting on my
behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity. I also understand that Ashley Valley Calvary Chapel or any of its staff or volunteers are not responsible for my personal belongings.
Furthermore, I understand and assume the expenses of any property damage caused by my child. Should it be necessary that my child be returned home due to disciplinary action (when on trips), I will be contacted by the leaders and will be responsible to pick my child up and assume the cost of transportation (see Student Expectations & Behavioral Covenant).

*No possession or use of alcohol, marijuana/cannabis, illegal drugs, tobacco, nicotine or vaping products, or misuse of prescription or over-the-counter medications.
*No fighting, weapons, fireworks, lighters, or explosives tolerated.
*No physical or verbal abuse (including profanity) will be tolerated.
*No offensive, immodest or suggestive clothing. Respect yourself by dressing appropriately!
*No inappropriate public displays of affection, including kissing or inappropriate physical contact.
*No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters.
*No wandering off alone! You must always tell your leader where you are going and bring at least one other person
along with you.
*No students can drive other students to an event (from the church to an event) without written parental consent.
*Participation with the group is expected at all times. Students may not wander off to do their own activity.
*Respect and a cooperative attitude for everyone inside and outside of the group is an expectation.
*Respect the rights and all property of others (restaurants, campuses, each other, etc.).
*Respect for staff and adult leaders. Disrespect will not be tolerated.
*Respect and comply with the event’s schedule.
*Follow the direction of the staff leadership.
*Cell-phone use will ONLY be allowed outside of times of worship, messages, and teaching.
*Absolutely NO PRANKING allowed! (Pranking always ends up crossing the line).

Students who fail to comply with these expectations may be sent home at the expense of their parents or guardians. If parents or guardians cannot or will not pick up their student, transportation will be arranged for the student to be sent home. In the case of a first offense (depending on the incident), a warning will be given to the student, with potential additional disciplines (including restricted free time, cell-phone usage, separation from the group, etc.). In the case of a second or repeated offense (depending on the incident), a student will more than likely be sent home. In all cases, the ministry’s benefit to the student and the entire group remains the primary goal. Discipline is always administered for the good of the student and the group.

I have read the above statements and am in agreement with them, and will, if deemed necessary by the leadership, agree to pick up my child at my expense.

Parent 1 Signature

Parent 2 Signature

Child Signature

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