Medical & Event Release Form

"*" indicates required fields

Youth's name for which the following statements are made:*

Permission, Medical, and Liability Release Statement

I give my permission for my daughter/son to participate in any local and/or out of town events on any date with First Presbyterian Church Youth Ministry.
  • I understand that activities may involve risk of personal injury and/or property damage, or loss of person or property. And, I hereby waive and release all claims or rights against First Presbyterian Church, its officers, directors, coordinators, adult advisors, and all owners of equipment which may be used in this event for any and all injury, damage, or loss of person or property incurred during this event.
  • I understand that all participants are expected to conduct themselves in an appropriate manner and to obey the adult chaperones.
  • I understand that I will be contacted as soon as possible concerning any medical or behavioral problem with my youth.
  • I give my permission for, and will accept financial responsibility for, the adult chaperones to act on my behalf in the event of a medical emergency for my daughter/son.
  • I have reviewed the information that is on the Medical Information Form and it is correct to the best of my knowledge.
MM slash DD slash YYYY

Parent Contact Information


Emergency Contact Info (if parent/guardian is not available)


Medical Information Form

Child's Name*
MM slash DD slash YYYY
Policy Holder's Name*
MM slash DD slash YYYY
I give my permission for FPC staff/chaperones to provide my child with over-the-counter medication (Children's Tylenol, Benadryl, Dramamine, Pepto Bismol, etc.)
Check if you have a history with these medical conditions:*
This field is for validation purposes and should be left unchanged.