2024-25

Family Medical Release

For any youth attending a special event or trip, a medical release form is required to participate.

You only need to complete one form per household. Have your insurance card ready and the tetanus vaccine information for each youth. This release covers your youth from August 2024 through August 2025.

Family Information

Family Last Name

Parent/Guardian 1 Full Name

First Name

Last Name

Parent/Guardian 1 Email Address

Parent/Guardian 1 Phone

Youth 1 Information

Youth 1 Full Name

First Name

Middle Name

Last Name

Youth 1 School

Youth 1 Birth Date

Youth 1 Date of Last Tetanus Shot

Add another child?

Yes

Youth 2 Full Name

First Name

Middle Name

Last Name

Youth 2 School

Youth 2 Birth Date

Youth 2 Date of Last Tetanus Shot

Add a third child?

Yes

Youth 3 Full Name

First Name

Middle Name

Last Name

Youth 3 School

Youth 3 Birth Date

Youth 3 Date of Last Tetanus Shot

Medical & Insurance Information

Insurance Card Photo FRONT

Insurance Card Photo BACK

Allergy Information & Medical Contingency if Exposed

Emergency Contact Information

Emergency Contact Full Name

Emergency Contact Phone Number

Physician Information

Youth Primary Care Physician Full Name

First Name

Last Name

Physician Phone Number

Acknowledgements

By signing my name below, I acknowledge that this health information is correct so far as I know, and I expressly consent to the participant's involvement in all activities and events from August 2024 - August 2025.
First Presbyterian Church sponsors various activities for its youth. I give permission for my child to participate in any Church-sponsored activity that my child attends. I further give permission for my child to ride with a driver age 18 or older to and from those activities. I understand that with any activity, including transportation, there is the chance of injury to person or damage to property and that with any activity, there is the risk of multiple types of infectious disease, including one caused by a coronavirus, such as Covid-19. Notwithstanding the risk, I release, relieve, and hold harmless First Presbyterian Church, its employees, members, and volunteers (including drivers) from any and all liabilities, including liability resulting from injury to person or damage to property or from contracting a contagious disease, arising out of my child's participation in a Church-sponsored activity, including transportation provided by a driver age 18 or older.. Further, in the event my child is injured at a Church activity and requires medical treatment, I give permission to any adult leader (age 18 years or older) to authorize such medical treatment as he or she determines appropriate in consultation with medical professionals, and I agree to be financially responsible for such medical treatment. It is not unusual for youth to ride with their peers who are licensed to drive. I understand and agree that the Church does not and will not accept responsibility for injuries or damages resulting from my child riding with their peers to or from Church activities. I agree to be responsible for transporting my child to and from church functions if I do not want them riding with their peers. I understand that he/she may be photographed, and that these photographs may be included in publications, social media posts, and web sites of First Presbyterian Church of Nashville.
I hereby release First Presbyterian Church and its staff and sponsors from responsibility and liability for any injury or illness that my child may sustain during church-sponsored activities. In the event of an emergency, I hereby authorize an adult leader of the activity, as agent for me, to consent to any examination or treatment by physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible.

Signature of Parent or Legal Guardian

Date

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Youth

Helping our 7th through 12th graders know and follow Jesus.

Since 1814

To know Christ and to make Him known.

Worship with us Sunday at 8:30 or 11:00 a.m.

Founded in 1814, First Presbyterian was born by grace. We are an outpost of the kingdom, called to glorify the Triune God, to make known the crucified and risen Christ, and to advance the gospel of God’s free and redeeming grace. Whether you are a long-time member or are new to First Presbyterian, we would love to help you find ways to get more connected.

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2024-25

Family Medical Release

Family Information

Youth 1 Information

Medical & Insurance Information

Emergency Contact Information

Physician Information

Back to Youth Ministry Home

Youth

Since 1814

To know Christ and to make Him known.

First Presbyterian Church Nashville