Youth and Children’s Ministry Medical / Liability Release Form

Ensuring the safety and well-being of your child or student is our top priority at St. Paul Church of Columbus. This Medical & Liability Release Form must be completed only if requested by program staff. Once submitted, the form will be valid for all necessary events from September 1, 2024, through August 31, 2025, so you won’t need to complete it again during this period.

Steps to Complete the Form:

1️⃣ Select the Event – Choose the specific event from the drop-down menu.
2️⃣ Upload Insurance Card – Have a clear copy of the front and back of your student’s medical insurance card ready to upload.
3️⃣ Submit the Form – After submission, you’ll be directed to a page for electronic signature of the consent form.
4️⃣ Review & Sign – Carefully read the consent form before signing, as it outlines important terms and conditions.
5️⃣ Receive Confirmation – A copy of the signed form will be emailed to you for your records.

Your cooperation in completing this form helps us create a safe and secure environment for all participants. Thank you for your attention to this important step!

Choose Youth or Children's Event(Required)

Participant Information

Because information is unique to individuals, a separate form is required for each participant of the same family.

Student's Name(Required)

First Last Suffix

If necessary, SUFFIX is Jr, Sr, II, III, etc.

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

Parent / Guardian Information

Name of Parent / Guardian Completing this Form(Required)

First Last Suffix

This person will be required to electronically sign this form when completed. If necessary, SUFFIX is Jr, Sr, II, III, etc.

Cell Phone of Parent / Guardian Completing this Form(Required)

Work Phone of Parent / Guardian Completing this Form(Required)

Email of Parent / Guardian Completing this Form(Required)

Enter Email Confirm Email

Completed and signed form will be emailed to this address after signed by this person.

Name of Other Parent / Emergency Contact(Required)

First Last Suffix

If necessary, SUFFIX is Jr, Sr, II, III, etc.

Cell Phone of Other Parent / Emergency Contact(Required)

Work Number of Other Parent / Emergency Contact(Required)

Health Insurance / Medical Information

Physician(Required)

First Last

Physician's Phone(Required)

Medical Insurance Company(Required)

Group Number(Required)

Policy Number(Required)

Picture of the Front and Back on Medical Card

Drop files here or

Max. file size: 100 MB.

List and Allergies, Recent Illnesses or Injuries, Current Medications, or Other Health Information(Required)

If none, type “NONE”

Estimated Date of Last Tetanus Booster(Required)