Gearhead Student Ministries - Medical and Permission Slip

This form must be completed and returned to a Gearhead Student Ministries staff member before a student may participate in events.

Medical & Permission Slip

Gearhead Student Ministries - Medical & Permission Slip
  • Date Format: MM slash DD slash YYYY

  • I hereby give permission for this student to attend and participate in Gracepoint Fellowship's Gearhead Student Ministries events in 2018 (January 1 – December 31)

  • PERMISSION TO TREAT A MINOR
    I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and/or dental services rendered to the aforementioned student or youth pursuant to this authorization.

  • PHOTOGRAPH RELEASE
    I hereby grant permission to Grace Point Fellowship to use photographic images containing photograph and likeness of said minor for various purposes such as printed material, publications, displays, video productions, Pro Presenter presentations, etc., as well as for the various Grace Point-related sites on the World Wide Web (WWW). I also acknowledge Grace Points right to crop or treat the photographic image at its discretion.

  • Please list any info (medication, allergies, ect.) that we need to know to better look after your teen:
  • This field is for validation purposes and should be left unchanged.