Milestone Clinton Student Activities Consent Form - 2025

This form will provide the student leaders with the necessary information and consent needed to allow students to travel with student leaders to/from any student ministry events or activities for the calendar year 2025.

When it asks for "Your name" please use the student's name in that field.

Your name *

Email address *

Student Information

Gender

Birthdate

Student Grade (or last completed) *

Photo Release

I agree that Milestone Church may photograph and record my student's likeness and activities (images) during church related activities and post the photos and videos on social media.

Parent/Guardian Information

Name(s) *

Address

Email(s) *

List all phone numbers where the parent/guardian can be reached by type (i.e. home, cell) *

Additional Emergency Contact (Include Name, Number, Relation) *

Medical Information

Medical Insurance Company

Insurance Phone Number

Insurance Policy/Group#

Insurance Policy Holder's Name

List any current medical conditions (i.e. asthma, diabetes, epilepsy)

List any current medications

NOTE: Students may keep any medications, supplements, vitamins, etc. in their possession during trips ONLY IF the leaders are aware of it and the parents feel they are mature enough to manage their own medications.

Student's Blood Type (if known)

Please explain any other pertinent information (physical, emotional, or behavioral) about the participant that may be necessary or useful for the leaders to know (like sleepwalking!).

Authorization

Participation *

I, the undersigned, being the parent or legal guardian of the student named above, do hereby consent to the participation of my student in any of the scheduled student activities, events, retreats, and trips of Milestone Church. Further, This includes permission for my student to ride in any vehicle driven by an approved and licensed adult chaperone while attending and participating in these activities and events. I certify that my student is physically fit and adequately prepared to participate in all recreational and sporting events. If I wish to revoke my consent for any reason, I will promptly notify the student leader in writing.

Medical Treatment *

I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my student is injured or becomes ill. I authorize the student leaders and adult chaperones to make emergency medical care decisions on behalf of my student, if required by law or a health care provider. I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that neither Milestone Church nor the student ministry leaders will be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the student director in writing of any health changes that would restrict my student's participation in any normal student activities. I also understand that the student leaders and designated adult chaperones reserve the right to restrict my student from any activity that they do not feel is within the physical capabilities of my student.

Student Pledge *

I hereby pledge to uphold all policies of Milestone Clinton student ministries. During all student activities and all strudent trips, I pledge to follow all instructions of the student leaders and the adult chaperones, including safety instructions.

Parent / Guardian Signature (First and Last Name) *

Youth Signature (First and Last Name) *

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