immersion online release form – Bridge Street Ministries

Please select which trip you are registering for*
Church or Organization Name:*
Church or Organization Name:*

Medical Information
This information is required in case of an emergency. All information provided will be held in confidentiality.
Health Insurance Company
Name of Policy Holder
Policy Number
Group Number
Doctor's Name
Phone
Hospital Preference
Date of Last Tetanus Shot
MM
DD
YYYY
Please list any physical limitations that might hinder participation in activities (allergies, asthma, migraines, etc.)
Medications
Please list medications and doses that are taken regularly.
List
Medication Dosage Specific times taken each day Reason for taking
Allergies
Medication, Food, and Other Allergies Describe reaction and explain how it is managed

List all known
Release Form
Immersion Participant is:*
Minor Student (under 18)
*
- I hereby certify that I am the parent or legal guardian of the above named participant and I give my permission for him/her to take part in any of the activities sponsored by the Bridge Street Ministries (BSM). I am aware that there may be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless expenses or damages of any kind growing out of or related to any activities or transportation to and from activities. My signature below authorizes the BSM to photograph my child for use in BSM publications and/or future promotional materials.
Signature
Parent or guardian if under 18 years old. Participant if over 18 years old.
Adult student or leader (Must be over 18)
*
- I hereby certify that to the best of my knowledge I am in a state of health sufficient for me to take part in any of the activities sponsored by BSM without jeopardizing my well-being. I am aware that when taking part in activities like this there may be risks and dangers which I will assume personal responsibility for and will release and agree to indemnify and hold harmless to BSM, its officers and directors, employees, and any parties volunteering on behalf of BSM, from all actions, costs, expenses or damages of any kind growing out of or related to any activities or transportation to and from the activities. My signature below authorizes the BSM to take my photograph for use in BSM publications and/or future promotional materials.
Date
MM
DD
YYYY

Step 1 of 3

General Information

Background Check Information

Emergency Contact

Medical Information

Medications

Release Form

Minor Student (under 18)

Adult student or leader (Must be over 18)

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Medication	Dosage	Specific times taken each day	Reason for taking

Medication, Food, and Other Allergies	Describe reaction and explain how it is managed