Shoreline Church Medical Release & Permission Form

Effective Dates: December 1, 2010 to December 1, 2011.

Name: ___________________________________Age: ____ Birthday: ___________________

Mobile Phone: _________________ Texting? Y or N Email: ___________________________

Address: ______________________________________________________________________

Parent(s)/Guardian(s): ___________________________________ Phone: __________________

Doctor: _______________________________________________ Phone: _________________

MEDICAL HISTORY: If necessary, describe in detail the nature and severity of any physical
and/or psychological illness or limitations to which your child may have, and what, if any action
of protection is required by an adult, please include names of any medications with dosage that
must be taken.__________________________________________________________________

______________________________________________________________________________
______________________________________________________________________________

Circle the following areas of concern for your child.

Swimming Allergies Asthma Seizures Heart Trouble Diabetes Other:___________________

Please explain below (for additional space, use the back of this form).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Should your child be restricted from any activities for any reason? If yes, please explain.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

RULES OF CONDUCT: We expect each teen to conform to these rules of conduct.

No possession or use of alcohol, drugs or tobacco. No offensive language.

A teen may only drive themselves to youth events. No other teens will be allowed to ride along.
No fighting, weapons, fireworks, lighters or explosives.
Teens are to dress in appropriate clothing for any youth event. Youth Leaders will use their own
discretion of what is deemed appropriate.
Respect your leaders, one another, & the property of others.

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Teens who fail to comply with these expectations during any youth event/activity may have
privileges taken away or at out of town events may be sent home at their parents’ expense.

As a youth at Shoreline Church, I have read the rules of conduct, the evaluation of my health &
permission to participate in youth group activities. I agree to abide by the stated personal
limitations and code of conduct.

Signed: __________________________________________Date: ________________________

EVENT PERMISSION:

Parents: If you desire to limit your child’s participation in any event, please submit your
wishes in writing prior to the event day to a youth leader of Shoreline Church

My child has my permission to attend youth activities/events hosted by Shoreline Church from
12/1/2010 to 12/1/2011 unless I notify a leader in writing.

This consent form gives permission to seek whatever medical attention is deemed necessary, and
releases any liability against personal loss of named child. I/We the undersigned have legal
custody of the child named, and have given our consent for the child to attend events being
organized by Shoreline Church.

I/We the undersigned, understand that there are inherent risks involved in any ministry or event,
and hereby release Shoreline Church, it’s Pastors, employees, agents and volunteer
worker/chaperones from any and all liability for any injury, loss, or damage to the 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
doctor or hospital personnel designated by Shoreline 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.

Parent(s)/Guardian(s) Signature ___________________________________________________

Printed Name(s) ________________________________________________________________

Date:_____________________________

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