Holly Springs Baptist Church Release Form

Effective dates: August 13, 2017 to August 30, 2018

Year in school:
Phone: Home
Phone: Cell
Mother's name:
Mother's Phone: Home
Mother's phone: Cell
Father's name:
Father's phone: Home
Father's phone: Cell
Emergency contact:
Emergency contact phone: Home
Emergency contact phone: Cell
Physician Phone:
Dentist Name:
Dentist Phone:
Medical History
Medical Profile Generally, the participant's Health is:
If Fair or Poor, please explain the condition:
List any medical difficulties which are currently being treated:
Check any of the following that cause you problems & explain:
Explain any of the above problems:
List any medicines or substances to which you are allergic:
List any previous operations or serious illnesses:
List any medications you are currently taking:
List any special diet or special needs:
Childhood Diseases:
Please explain if you answered "other" above:
Date of Tetanus Immunization:
Family Physician:
Family Physician Phone:
Insurance Co:
Policy #:
Subscriber Name:
Subscriber Number:
Subscriber Occupation:
Work Phone:

For your information, we expect each student to conform to these rules of conduct:

  • No possession or use of alcohol, drugs or tobacco
  • No fighting, weapons, fireworks, lighters or explosives
  • No offensive or immodest clothing
  • No boys in girls' sleeping quarters and no girls in boys' sleeping quarters
  • Full participation with the group is expected
  • Respect property
  • Respect one another, staff and adult leaders
  • Respect and comply with event schedules
  • Demonstrate the fruits of the Spirit in all situations

Students who fail to comply with these expectation may have their privileges suspended and may be sent home at their parents' expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities.  I agree to abide by the stated personal limitations and code of conduct.

Student Signature:

Activities may include, but are not limited to:  cookouts, boating, water skiing, swimming, basketball, roller-skating, rollerblading, games in the park, skateboarding, soccer, ice skating, volleyball, softball, baseball, paintball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides.  Note:  Transportation to and from events and activities held off of the church's campus will be provided by Holly Springs Baptist Church who will enlist responsible adults to operate the vehicles.  If you wish to limit your child's participation in any event or activity, please submit your wish in writing to the Minister of Youth.

Student Name

has my permission to attend all youth activities sponsored by Holly Springs Baptist Church from August 30, 2016 to August 30, 2017.

Permission for Medical Treatment, Photography/Video Notice and Release and Indemnity

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by Holly Springs Baptist Church. I/We understand that there are inherent risks involved in any ministry or athletic even, and I/we hereby release the Church, its ministers, employees, agents and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at the date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. Also, I/we understand that as a participant, my child may be photographed or videotaped during normal church or event activities, and these photos/videos may be used in promotional materials.

I, the undersigned, do hereby verify that the above information is correct, and I do hereby release and forever discharge Holly Springs Baptist Church from any and all claims, costs, demands, actions or causes of action, past, present or future arising out of any damage or injury in connection with my or my child's employment by or participation in any church events.

Parent/guardian signature:
Signature Date:
Word Verification: