Youth Ministry Events & Trips Medical Release Form

  • If student does not have a cell phone please enter 000-000-0000
  • If student does not have a home phone please enter 000-000-0000
  • Medication

  • Please check off the "OTC's" your child is NOT allowed to use.
  • Allergies

  • Insurance Information

  • If the student does not have health insurance coverage, please type NONE in the following three fields. If no health coverage is available the parent/guardian will be responsible for any medical bills incurred during this event/trip.
  • Primary Medical Doctors

  • Things for Us to Know

  • Gaithersburg Presbyterian Church uses a variety of media to share with the community and the world the life and ministry of GPC. In doing so we, at times, post pictures of individuals or groups of people participating in GPC activities. These materials will not include any identifying information with any photos. Please indicate below whether or not you give your permission for us to post a photo taken that includes your son or daughter.
  • Parent / Guardian Information

  • If you do not have a home phone number please enter 000-000-0000
  • CONSENT & RULES

    We (I) authorize the Event Leaders, in whose care the minor has been entrusted to secure medical treatment as deemed necessary by the Event Leaders including but not limited to, examination, x-ray, hospital care, injections, anesthesia, surgery, and any other medical or dental diagnosis or treat for the child/ward. We (I) further authorize said Event Leaders to sign any consent thereto as fully as if we (I) could if we (I) were personally present.Whenever feasible and possible the Event Leaders will attempt to contact the parent/guardian(s) for guidance and direction and will attempt to all the parent/guardian(s) to speak with any health care provider prior to any procedure or treatment. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforesaid child pursuant to this authorization. Shall it be necessary for our (my) child/ward to return home due to medical reasons, the undersigned shall assume all medical costs. The undersigned does also give permission for our (my) child/ward to ride in any vehicle designated by the Event Leaders, in who's care the minor has been entrusted while attending and participating in activities sponsored by Gaithersburg Presbyterian Church. The Gaithersburg Presbyterian Church is pleased to provide programs and activities as part of its Ministry. Participation in programs and activities are contingent upon the participant's appropriate Christian behavior. Any participant not conducting himself/herself in this manner at any program or activity will be required to leave the program or activity at the expense of the parent/guardian when so informed by the Event Leaders in whose care the minor has been entrusted. In consideration of my permission for (Child's Name) to attend the activities, I do herby release and discharge Gaithersburg Presbyterian Church, the Staff, and the Event Leaders from all claims, injury, or property damage during the participant's participation in activities herein, and further agree to indemnify and hold harmless Gaithersburg Presbyertian Church, the Staff, and the Event Leaders from all claims, actions and causes of actions,, that may at any time be made or brought for injuries or damages arising out of activities sponsored by Gaithersburg Presbyertian Church.
  • For your information, we expect each student to conform to these rules of conduct. Students who fail to comply with these expectations may be sent home at their parent's expense.
  • Please Sign