STUDENT Medical Release Form

EFFECTIVE JUNE 1, 2021 - MAY 31, 2022

**Participants Under 18 Years of Age Must Have This Form Signed by a Parent or Legal Guardian**

Student's / Child's Info*

Parents' / Guardians' Info


I acknowledge that I am voluntarily participating in the NextGen Ministry activities of CENTRAL WESLEYAN CHURCH of HOLLAND, MICHIGAN (“Church”), including Church-provided transportation to and from such activities. I acknowledge that there are certain risks associated with these activities, including injury, illness or death.

I understand that activities may involve special events such as camp retreats and events at amusement venues. I understand that during these events I may take part in activities such as: roller skating, go-kart racing, miniature golfing, obstacle courses, batting cages, and laser tag, etc. I further understand that I may participate in local Church-sponsored service projects which may involve activities such as: painting, climbing ladders, yard work, heavy lifting, various light construction work, and athletic activities.

Release from Liability
I certify that I am capable of withstanding both the physical and mental demands of the activities discussed above. I also certify that I have no health-related conditions precluding my participation in the above activities. In exchange for my participation in Church activities, I expressly assume all risks of participating in the above activities, whether such risks are known or unknown to me at this time. I further release the Church, its ministers, employees, trip leaders, volunteers, representatives, and agents from any claims, actions, liabilities, or damages I may have against them as a result of injury, illness, death, or personal property damage incurred during the course of participation in the above activities, including Church-provided transportation. This release of liability is also intended to cover all claims, actions, liabilities, or damages that members of my family or estate, heirs, representatives, or assigns may have against the Church or its ministers, employees, trip leaders, volunteers, representatives, or agents.

I knowingly and freely assume all risks, both known and unknown, my child has of possible exposure and contraction of illnesses from infectious diseases including but not limited to MRSA, influenza and COVID-19 while attending Church events, even if arising from the negligence of the releasees or others and will not hold the Church, its ministers, employees, trip leaders, volunteers, representatives, or agents responsible or liable. I am aware and acknowledge the contagious nature of infectious diseases including but not limited to MRSA, influenza and COVID-19.

I grant permission for photos and videos of my child to be used in the promotion of Central Students and the Church.


I understand that while participating in Church activities, emergency medical treatment may be necessary, and that the Church may be unable to contact a parent, legal guardian, or emergency contact for consent to emergency medical care. I consent to and give permission for the Church, its representatives, or agents (including but not limited to trip leaders) to make emergency medical decisions, including decisions concerning medical, surgical, and hospital care, which may be deemed necessary under the circumstances. I further agree to assume all costs and expenses associated with such care to the extent they are not covered by my medical insurance.


Are you: *

The parent of a student/child?

A student 18 years old or older?