2026 Medical Release & Code of Conduct

This form will be for all off campus trips for 2026

1Personal Information > 2Rules of Conduct
Personal Information

Please fill out completely
Student's Name Student's Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Students Age
Students Grade
Students Shirt Size
Students Hoodie/Sweatshirt Size
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Student's Cell Phone Student's Cell Phone - ### - ### ####
Medical Insurance Company
Policy Number
Parent's Name Parent's Name First Last
Parent's Cell Phone Parent's Cell Phone - ### - ### ####
Emergency Contact/Phone Number
Physician/Office Number
Dentist/Office Number
Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, weakness, limitation, handicap, disability or condition to which your child is subject; and of which the staff should be aware. Also describe any action of protection that is required for that ailment, illness, weakness, limitation, handicap, disability or condition. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.

Check the following areas of concern for this student. If necessary, add another page with details:
For your child's safety, and our knowledge, is your child a:

For your child's safety, and our knowledge, is your child a: Good Swimmer Fair Swimmer Non Swimmer
Does your child have allergies to:

Does your child have allergies to: Pollen Medications Food Insect Bites Other Other
Does your child suffer from, or has ever experienced, or is being treated currently for the following:

Does your child suffer from, or has ever experienced, or is being treated currently for the following: Asthma Epilepsy/Siezure Disorder Heart Condition Diabetes Physical Handicap Frequently Upset Stomach Other Other
Date of Last Tetanus shot Date of Last Tetanus shot / MM / DD YYYY
Please list and explain any major illness your child has experienced during the last year:
Should your child's activities be restricted for any reason? If yes, explain:
Electronic and Print Media

Chestnut Ridge Baptist Church reserves the right to use both audio and video recording, along with still photography, at any church/youth event or activity. These images and recordings may be used in either electronic or print media. These images and recordings may be used to promote the church or youth functions and events. These images and recordings may also be used for the propagation of the church’s mission or ministry.
Transportation

I authorize Chestnut Ridge Baptist Church to transport my student in a Church owned vehicle or personally owned vehicle, driven by an individual authorized by Chestnut Ridge Baptist Church. I understand that my child is expected to follow all applicable laws regarding riding in a motor vehicle and is expected to follow the directions provided by the driver and/or staff or volunteer.
Parental Consent

My child [named below] has my/our permission to attend all church/youth events and activities sponsored by Chestnut Ridge Baptist Church (hereinafter the “church”).

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the church and its staff of any liability against personal losses of the child named herein.

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 the church. I/We understand that there are inherent risks involved in any ministry activity or event, 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 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 medical care should the cost of that care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student mentioned above. I/We agree to notify the church, in writing, of any changes to the information provided herein. 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. I/We agree to allow the church to use any audio and video recording, along with still photography, featuring the student named above in a manner that the church deems beneficial for promotion or the church or propagation of the church’s mission in or ministry.
Student's Name Student's Name First Last
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Today's Date Today's Date / MM / DD YYYY

2026 Medical Release & Code of Conduct

2026 Medical Release & Code of Conduct

Personal Information

Medical History

Electronic and Print Media

Transportation

Parental Consent