Please fill out Medical/Permission Form below for your student(s)* for the 2021-22 Program Year.

*Each individual student needs to have a completed form submitted.

Medical/Permission Form

  • Participant

  • Please use numerals only. (Use 0 for Kindergarten and under)
  • MM slash DD slash YYYY
  • Medical Information

  • Drop files here or
    Accepted file types: jpg, pdf, Max. file size: 400 KB.
    • Parents/Guardians

    • Medical Release

      We, the undersigned parent(s)/guardian(s), of the participant named above, hereby authorize emergency medical, dental, health, or hospital services be rendered to my child upon consent of a Ladue Chapel Presbyterian Church Staff member or designated advisor. The purpose of this authorization is to permit my child to receive emergency medical attention when needed while involved in activities connected with Ladue Chapel Presbyterian Church's Youth Groups when I or my emergency contact are unavailable to give such consent. This authorization shall be effective for the current program year - see dates above.
    • MM slash DD slash YYYY
    • Permission for Participation & Transportation

      We, the undersigned parents(s)/guardian(s) of the participant named above, hereby authorize the participant to participate in Ladue Chapel Presbyterian Ministry events for the current program year (listed above). It is understood that the designated advisors of Ladue Chapel will be in attendance and will provide the best reasonable supervision to ensure, welfare, and comfort of all in attendance. Youth Ministry events may be off-site, in which case we (I) hereby give permission for the participant to be transported to and from said event. We (I) hereby release Ladue Chapel Presbyterian Church, its designated advisors and staff, from any liability for any incident beyond the control of its advisors and staff using their due diligence and best judgement.
    • MM slash DD slash YYYY
    • Photography Release

      We (I) understand that the participant's image may appear in photographs taken at events which the participant has attended. We (I) hereby give Ladue Chapel the right to use images in which the participant appears in a manner which furthers the ministry of Ladue CHapel Presbyterian Church which may include but is not limited to: social media (Facebook, Twitter, Instagram, etc.), website, posters, and fliers.
    • MM slash DD slash YYYY