09-10 ANNUAL RELEASE FORM

A signed release form must be on file for students to participate in any ministry activity.
This also registers your student with the Families with Youth Ministry.

 I hereby grant permission for___________________________to participate in youth group activities of TOPC taking place from June 1, 2009, through June 30, 2010. We hereby release, forever discharge and agree to hold harmless TOPC, its staff, employees, leaders, volunteers, and any other agents from any and all liability, claims or demands for personal injury or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned and/or the youth participant that occur while said youth is participating in any church activity, event or trip, regardless of the location of such activity, event, or trip.

 I hereby grant permission and authorization to the sponsors of the group to seek and obtain such emergency aid or medical treatment as may be necessary in the event my child should be injured or become ill. I hereby authorize the doctor, dentist, or such medical agency chosen or retained by the youth leader or sponsor to administer the necessary emergency care, first aid, and/or medical treatment or services for the health and welfare of my child. I assume responsibility for any medical bills incurred. I understand that in the event medical treatment is required, every effort will be made to contact me.

 Name of Student_____________________________________    Date of Birth_________________

Address_____________________________________________ Zip ________________________

Home Phone: ____________________________ Cell Phone: ______________________________

Email:_________________________________________ Facebook: ________________________

School (09-10) _________________________________________    Grade (09-10) ____________

Allergies (food, drug, or environmental):_______________________________________________

Medications, medical conditions, dietary restrictions, or physical limitations: __________________ ________________________________________________________________________________

Insurance Carrier________________________________ ID or Group #:_____________________

Name of Primary Insured__________________________ Primary SS#:______________________          

Parents’ Names___________________________________________________________________

Parents' Phone Number(s) __________________________________________________________

If parents or guardian cannot be reached, other person to notify in case of emergency: Name/Relationship______________________________ Phone Number(s) ___________________          

R Please send me email updates/reminders:

Father’s email: __________________________________________________________________

Mother’s email: __________________________________________________________________

My child’s photo may be used on the church web site (no identifiers will be used) ___ Yes ___No

My child has permission to ride in the car of:  

 TOPC staff, interns, adult volunteers________________________ (please initial)

 Youth Ministry approved student drivers ____________________ (please initial)

_____________________________________                       ________________________________

Signature of Parent or Guardian          Date                     Name of Parent or Guardian (print)