Please contact Jacob Davis if you have any questions. 

jdavis@stpetersparish.org

ST. PETER'S STUDENT INFORMATION FORM 
Medical & Liability Release
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Student Information
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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?
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.
Medical Information
Permitted to take over-the-counter Pain & Cold Medicines
Additional Student Information
arrow&v
arrow&v
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?
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.
Medical Information
Permitted to take over-the-counter Pain & Cold Medicines
Is Insurance and Doctor information same as siblings? If yes, you do not need to input again.
Family Information

Home Address
Primary Contact
Secondary Contact
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 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. 

Thank you for submitting your information!

Please contact the church office if you have any questions. 

904-261-4293