St. Peter's Episcopal Church | Fernandina Beach

Please contact Jacob Davis if you have any questions.

jdavis@stpetersparish.org

ST. PETER'S STUDENT INFORMATION FORM
Medical & Liability Release

Student Information

First Name

Last Name

Nickname

Date of Birth

Pronoun

Grade for 2021-2022 School Year

Student Phone Number

Occasionally, our youth ministry staff will contact youth by text to check in or share updates about programs. Do we have permission to text this number?

Yes

We strive to make all people feel comfortable and welcome here. Does your student have any specific needs or considerations we should know about, so that we can provide the most safe and comfortable environment possible? If yes, we will reach out privately for further conversation.

Yes

Medical Information

Known Allergies

Current Medications

Permitted to take over-the-counter Pain & Cold Medicines

Yes

Insurance Company

Policy Number

Doctors Name

Doctors Phone Number

Additional Student Information

First Name

Last Name

Nickname

Date of Birth

Pronoun

Grade for 2021-2022 School Year

Student Phone Number

Occasionally, our youth ministry staff will contact youth by text to check in or share updates about programs. Do we have permission to text this number?

Yes

Medical Information

Known Allergies

Current Medications

Permitted to take over-the-counter Pain & Cold Medicines

Yes

Is Insurance and Doctor information same as siblings? If yes, you do not need to input again.

Yes

Insurance Company

Doctors Name

Policy Number

Doctors Phone Number

Family Information

Home Address

Street Address

City

State

Zip Code

Primary Contact

First Name

Cell Phone

Last Name

Email address

Relationship to Student

Secondary Contact

First Name

Last Name

Cell Phone

Email address

Relationship to Student

Release and Hold Harmless Agreement

In consideration for St. Peter's Episcopal Church (St. Peter’s) permitting the undersigned’s child to participate in its activities and events, the undersigned do hereby voluntarily agree to release and hold St. Peter's harmless, and their directors, trustees, officers, employees, leaders, and volunteers from all causes of action arising out of any negligent acts or omissions or otherwise which the undersigned and their heirs, personal representatives, administrators, assigns, guardians, wards, or successors may have against any of them for, or on account of, or by reason of the undersigned’s child participation in any of the activities and events of St. Peter's. This release and hold harmless agreement specifically preclude liability on behalf of St. Peter's, their directors, trustees, officers, leaders, employees, and volunteers for any personal injury to the undersigned’s child, or for damage or loss of the undersigned’s personal property, which arise from or are incident to the undersigned child’s participation in any of the activities and events of St. Peter’s.

Specifically, by checking the box, the undersigned further agrees to the following.

Consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that taken of the child of the undersigned during the activity/event to be used, distributed, or shown as St. Peter’s sees fit.

Consent to transportation in a personal vehicle driven by a St. Peter’s staff person or approved adult volunteer to and from St. Peter’s events.

Consent for Emergency Medical Treatment

I am the parent/legal guardian of the above named participant and I hereby authorize St. Peter's Episcopal Church and its representatives to act on my behalf in any emergency medical treatment that may be required. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required and to give specific consent to any and all such diagnosis, treatment or hospital care which a licensed physician in the exercise of his/her best judgment may deem advisable. I have read all the above-stated terms of the Release and Hold Harmless Agreement and understand its meaning fully and voluntarily agree to its terms. This authorization shall remain effective until one year from the date signed unless revoked in writing at an earlier date.

Signature of Parent/Legal Guardian

Date

Name of Parent/Legal Guardian

Thank you for submitting your information!

Please contact the church office if you have any questions.

904-261-4293

ST. PETER'S STUDENT INFORMATION FORM Medical & Liability Release

Student Information

Medical Information

Additional Student Information

Medical Information

Family Information Home Address

Primary Contact

Secondary Contact

ST. PETER'S STUDENT INFORMATION FORM
Medical & Liability Release

Family Information

Home Address