LWR Baptist Church - 2026 Student Permission and Medical Release Form

The Permission & Medical Release Form of Lakewood Ranch Baptist Church (LWRBC) covers all events of the UNITE student ministry for the 2026 calendar year. It must be filled out and submitted for any student under the age of 18 participating in a UNITE students sponsored event.

Parent First Name

Parent Last Name

Parent Email

Parent Phone Number

Parent Address

Parent Apartment, suite, etc.

Parent City

Parent State

Parent Zip/Postal Code

In the event of an emergency, please give the name and phone number of the friends or relatives we can contact who will know how to reach parents or guardians. YOU MUST COMPLETE THIS INFORMATION.

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Relationship Other

Family Physician Name

Family Physician Phone Number

Family Insurance Company

Insurance Policy Number

I, the undersigned, hereby verify...that the above information is correct and I do hereby release and forever discharge all sponsors and LWRBC, and its staff/representatives, from any and all claims, demands, actions, or cause of action, past, present, or further arising out of any damage of injury while employed or participating in the UNITE student ministry events. I further grant permission for my child to accompany LWRBC on approved trips of the church and to ride in approved vehicles with church approved drivers. The rights, powers, and authority of said representatives to exercise any and all of the rights and powers herein granted shall commence and be in full force and effect on the date listed below, and such rights, powers and authority shall remain in full force and effect thereafter until revoked by me in writing. At all UNITE student ministry events digital pictures are taken for the sole purpose of promotion. I understand that my son/daughter's picture may be used on our website or publications to promote UNITE student ministry events or the church.

By checking this box I agree to the above.

I have supplied, understood, and agree to all the information on this Medical Release Form

I agree that checking this box replaces my signature.

Date above box checked

Witness of agreement (Please type full name, if available, not necessary)

Date of witness

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