Permission/Release Form

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 Kids On Mission & 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.