Student Permission and Medical Release Form

2026 Permission and Medical Release

The Permission and Medical Release form only needs to be filled out once for each calendar year. The form below covers all LCC sponsored events and activities for the 2026 calendar year. If you have already filled this form out for a 2026 event or trip, you do not need to fill it out again. Please contact Andrew if you have any questions.

Student Name(Required)

First Last

Current Age of Student(Required)

Student Email

Student Phone Number

Student's health insurance company name, phone number, and member ID or policy number:

Any allergies? If so, please describe:

Any medication being taken at this time? If so, please list and explain:

Any other medical conditions we should be aware of that may impact participation? If so, please explain:

Parent/Guardian Statement(Required)

I/We the undersigned have legal custody of the student named below, a minor, and have given our consent for him/her to attend events being organized by LCC. I/We understand that LCC will provide me information prior to each upcoming event.

Youth events and activities at Lexington Community Church (LCC) may include, but are not limited to: cookouts, swimming, basketball, roller skating, rollerblading, ice skating, games in the park, soccer, volleyball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, miniature golf, hayrides, and overnight events on or off the church grounds.

I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release and indemnify LCCC its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement.

In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician.

In the event treatment is required from a physician and/or hospital personnel designated by LCC, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.

I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider.
Further, I/we affirm that the health insurance information provided below is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above.

I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

I understand and agree with this medical release statement, and my child has permission to attend LCC sponsored activities and events during the 2026 calendar year.

Do you consent for your child to be photographed or recorded in connection with youth activities, and release LCC, its staff, and its volunteers from liability in connection with such photographs or video footage.

Yes

Signature(Required)

I understand that typing my name below constitutes my legal electronic signature.

Name (Signature) of Parent or Guardian(Required)

First Last

Relationship to child(Required)

Parent or Guardian Phone Number(Required)

Parent or Guardian Email(Required)

Name of Additional Emergency Contact(Required)

First Last

Emergency Contact Relationship to child(Required)

Phone Number of Emergency Contact(Required)