C3 Medical Release Form
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2Medical Release Form
C3 – Conroe Community Church l 206 A South Loop 336 West#151 l Conroe,
TX 77304
(936) 647-1414
Both sides of this form must be completed on all persons under 25 years of age and notarized.
Name_______________________________________________Age________Sex__________
Social Security Number_____________________________________Birthdate_____________
Address____________________________City___________________State_____Zip_______
Home Phone_________________________ Cell Phone_______________________________
Emergency contact other than Parent/Guardian______________________________________
Home Phone______________________________ Work Phone_________________________
Cell Phone_________________________________
The undersigned, as parent or guardian of the person listed below, hereby authorizes any staff member and/or
adult sponsor who may be supervising or directing any activity sponsored by C3 – Conroe Community Church,
Conroe, Texas, to authorize emergency medical treatment for the person listed above while this person is
participating in any trip, excursion or activity sponsored by C3 – Conroe Community Church, Conroe, Texas.
Furthermore, I release C3 – Conroe Community Church, its staff, employees and sponsors from any liability for
personal injury, damage or loss that the above named person may sustain while participating in any activity
sponsored by C3 – Conroe Community Church, Conroe, Texas, even if such personal injury or other loss is
caused by the ordinary negligence of C3 – Conroe Community Church, its employees, staff members or
designated sponsors.
Media Release
I agree to allow C3 – Conroe Community Church to use photographs and video recordings of my student(s) for
promotional and other purposes. Distribution of footage may be through pictures/videos posted on the internet,
in print or on other forms of publication.
I give permission to use footage of my student (please initial)
_____________.
I DO NOT give permission to use footage of my student (please initial)
_____________.
Printed Name of Parent/Guardian_______________________________________________
Signature of Parent/Guardian ___________________________________Date__________
Parent/Guardian Phone: Cell ________________________Work____________________
* * * * *
State of Texas
Subscribed and sworn to (or affirmed) before
County of ________________________
me on this ________ day of _____________
date
month
20____ , by _______________________ ,
name of signer
year
proved to me on the basis of satisfactory evi-
S E A L
dence to be the person who appeared before
me.
Signature ____________________________
Signature of public notary
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