We are so excited that your student is joining St. Paul Student Ministry for a trip. Our Medical Release form seeks authorization to make medical related decisions for your child and to photograph or video your child when attending activities and events sponsored in whole or in part by St. Paul Ocean Springs during the 2025 ministry year. Unless specified below, this authorization, when electronically signed by any parent or guardian, will remain in full force and effect for any St. Paul activity or event until expressly revoked in writing and delivered to the Office of Youth Ministry at St. Paul.

MEDICAL RELEASE FORM

Please Complete one medical release form per student. If you have any questions, please contact Selby at selby@stpaulos.org.

Student Name *

First Name

Last Name

Student Cell Phone *

(###)

###

####

Gender *

MALE

FEMALE

Student Age *

Student Grade *

Student Birthday *

YYYY

Student Social Security *

Please Note that All Form Submissions are completely secure.

Parent / Guardian Name *

First Name

Last Name

Parent / Guardian Phone *

(###)

###

####

Alternate Phone *

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Information

Insurance Company Name *

Group Name/Number (if applicable)

Policy Number *

Name of Primary Insurance Holder *

Birthday of Primary Policy Holder *

YYYY

Emergency Contact Information

In the event that a parent / guardian cannot be reached, please provide an emergency contact.

Name

First Name

Last Name

Phone

(###)

###

####

Allergy Information

Medical history/known allergies to food, drugs, bee stings, etc. *

Please list any medications currently taken *

Should the need arise for simple, over-the-counter medication, my child MAY BE GIVEN *

Ibuprofen

Tylenol

Benadryl

Pepto Bismal

Allergy Medication Cream

Tums

Melatonin

Cough Medication

Please do not give my child any over the counter medication.

Is there any other medical, emotional, social, or relational information that you think staff should be aware of? *

I grant full permission for St. Paul Ocean Springs to use still images or videos of my child participating in their ministries, programs or events, including but not limited to electric, print materials, or social media. *

I Do.

Are you or your spouse (the parent/guardian) interested in being an adult leader for this trip? *

We desperately need chaperones!

Yes we would love to pour into the generation of tomorrow!

I understand that in order to go on a trip with St Paul Student Ministries, I will be expected to treat others with respect and kindness. I understand that I cannot bring or use drugs, alcohol, tobacco, e-cigarettes, vapes, explosives, fireworks, or weapons on St. Paul property or retreat property. I understand that profanity, inappropriate joking, or hurtful words will not be tolerated. I understand that I cannot engage in inappropriate behavior, including but not limited to physical interaction, sexting, the sharing or displaying or pornographic, lewd or otherwise offensive images, etc. I understand that I am held responsible for any property that I break, damage, or otherwise alter intentionally. I understand that I am expected to follow these guidelines, and the breaking of them could result in being sent home, dismissed from the group, or other appropriate actions as deemed appropriate by Tweens Pastor, Selby Oltremari, in collaboration with St. Paul Staff Pastor Parish Relations Committee. *

I do

Thank you!

First Name

Last Name

Email Address

We respect your privacy.

Thank you!