2025 Medical & Permission Form - For students in the Nursery - 5th Grade

Name of the Adult filling out this form for the minor listed below *

First Name

Last Name

I give permission for my Minor/Student to attend all the calendared promoted events: Sunday School, Tuesday's Parenting Class, Women's 1 Day Event, H.U.G.S, X-Zone Program on Wednesdays, X-Zone Movie Nights, X-Zone Winter Camp, X-Zone Summer Camp, and La Jolla Presbyterian Church Vacation Bible School (VBS). Additional events not listed here will require an additional permission form. *

Yes

No

If you checked no: My Minor/Student only has permission to attend the following event(s). Please select all that apply.

X-Zone Program on Wednesdays

X-Zone Movie Nights

X-Zone Extravaganza

X-Zone Summer Camp

VBS - June 23rd - 27th

Sunday School

Tuesday's Parenting Class

H.U.G.S.

LJPC Events taking place on LJPC campus

Name of Minor *

First Name

Last Name

Birthday of Minor *

MM

DD

YYYY

Gender of Minor

Female

Male

Mother's/Guardian's Name *

Write in N/A if not applicable

First Name

Last Name

Mother's/Guardian's Name *

Write in N/A if not applicable

First Name

Last Name

Mother's/Guardian's Phone Number *

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Mother's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's/Guardian's Name *

Write in N/A if not applicable

First Name

Last Name

Father's Phone *

(###)

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Father's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

Alternate Adult (Please list an adult other than Mother/Guardian or Father/Guardian of the minor listed on this form) - Emergency Contact relation to Minor/Student

First Name

Last Name

General Release - Participation *

I, as primary guardian of the aforementioned minor/student give permission for my minor/student to participate in X-Zone activities and events both on and off of the La Jolla Presbyterian Church (LJPC) campus for the period of January 1st - December 31st, 2025.

First Name

Last Name

General Release - Participation *

I, as primary guardian of the aforementioned minor/student give permission for my minor/student to participate in X-Zone activities and events both on and off of the La Jolla Presbyterian Church (LJPC) campus for the period of January 1st - December 31st, 2025.La Jolla Presbyterian Church (LJPC) from all responsibility related to medical issues, illnesses, or injuries that may occur to my minor/student during any X-Zone activities or at any X-Zone events. The Participant/parents/legal guardian accepts personal financial responsibility for any injury or other loss sustained during the activity or event and releases and promises to indemnify, defend, and hold harmless LJPC, the LJPC staff, volunteers, or other attendees for any illness or injury arising directly or indirectly out of the activities or events. I acknowledge that participation in the activities or events involves risk to the Participant. No matter the injury, I acknowledge and accept the risks of injury associated with participation in the event. I further accept full responsibility for any medical expenses that may be incurred in the event my minor/student needs emergency medical treatment and I promise to indemnify, defend and hold harmless LJPC, LJPC staff and volunteers, or other attendees for any medical expenses incurred by my minor/student.

First Name

Last Name

Departing from Program/Events *

APPLIED TO ALL STUDENTS AND CHILDREN I agree to pick up or arrange for my minor/student to be picked up by an adult from program/event within 10 minutes of stated end time.

Yes

No

Leaving the church campus *

I give permission for my minor/student to leave the church when supervised by the youth leadership for appropriate activities related to X-Zone (i.e. Christmas Caroling)

Yes

No

Transportation *

I give permission for my minor/student to be transported by bus, van, or car to and from church events that happen offsite.

Yes

No

Films *

I agree to allow my minor/student to watch any films rated G, PG, or PG-13 which may be shown (at the Family Ministry Director’s discretion) as devotionals, bible study segments, or for entertainment purposes. I understand that whenever possible, film titles will be provided ahead of time. I understand that the youth leaders will never show an R rated movie without my permission and a separate permission slip will be provided if such a case were to occur.

Yes

No

Media Consent *

I hereby give my full consent to La Jolla Presbyterian Church (LJPC) and its ministries to record (video, photograph, audio, recording or other) my and my child's participation in any programs or events associated with LJPC X-Zone. Further, I hereby transfer and assign to LJPC the exclusive rights to use and to authorize others to use said images, video, photography, audio recordings or other, for promotional and educational use or resource sale in the future. I understand that my and my minor’s/student's image, voice or video recording may be used, but my name or personal information will never be shared publicly without additional, separate consent.

Yes

No

X-Zone Refund Policy

All X-Zone event payments can be refunded in full (30) days prior to the event. After the (30) day mark, half of payment will refunded. (1) week before the X-Zone event no refunds will be given. This policy is in place because of the logistics involved in reservations regarding student attendance; including camps, lodging, food budget, facility rentals, and extra cost given by vendors for X-Zone events. By clicking yes, I agree to the X-Zone Refund Policy

Yes

No

I would like to be added to the X-Zone email list so that I can stay informed about upcoming events and announcements.

Yes

No

Pursuant to California Family Code §6910, I, _______________(Please type your name below under parent/guardian)_________________, a parent/guardian having legal custody of ________(Please type your minor/student's name below)_________________________, a minor child, hereby authorize the adult leaders of the La Jolla Pres youth program into whose care such minor child has been entrusted, to consent to any X-ray examination (or similar examination such as by CAT scan), anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor by a dentist licensed under the provisions of the Dental Practice Act. I agree to pay any and all costs for the foregoing. *

Parent/Guardian Name

First Name

Last Name

Primary Care Physician Office Number *

(###)

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