Permission/Release Form Student Permission/Medical Release Form Student Name* First Last Student Birthdate* Date Format: MM slash DD slash YYYY Student Cell Phone (if applicable)Student Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Student Email Student School Attending*Current Grade for 2019-2020 School Year*Kindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thParent/Guardian Name* First Last Parent/Guardian Phone*Student Permission/Medical Consent* Check the Box to Give Consent I, the parent or guardian of the above student, a minor, do hereby authorize adult workers with the youth of Neshannock Alliance Church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services. I also release The Christian & Missionary Alliance staff and volunteers from liability resulting from any accident. In addition, I am giving permission for my student to participate in NAC Kids & REFUGE Youth Ministry activities, both weekly and at special events, on site and off site, for one full year from the above listed date. Also, I permit the staff/volunteers of Neshannock Alliance Church to contact my student via mail, social media, cell phone and/or email. Insurance Company or GroupPolicy Number No health insurance This iframe contains the logic required to handle Ajax powered Gravity Forms.