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Faith Lutheran Youth and Family Ministry Parental Consent and Medical Release Form Please print and complete this form and return to the Youth and Family Minister or the event coordinator.
Participant Name: _________________________________ Birth-date: __________ Grade: _____ Parent’s Name: ___________________________________ Work/Cell Phone: ________________ Address: ________________________________________ City/St/Zip: _____________________ Home Phone: __________________ Additional Info: ____________________________________
I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this document with binding legal effect. As the parent/guardian of _________________________(name of child), I certify and affirm that I have been completely and thoroughly informed that as a youth attending the ______________________________ (name of event), my child will participate in certain activities which carry with them a degree of risk and danger. Examples of risky or dangerous activities include but are not limited to: 1) physical activities, both indoor and outdoor; 2) sports, both informal and organized; 3) use of recreational equipment; 4) field trips, both on and off campus; 5) travel by automobile, 6) camping; 7) hiking; 8) activities around water, including swimming and boating; 9) adventure activities such as skiing, snowboarding, high ropes, rock climbing, etc. I acknowledge and understand that Faith Lutheran Church may offer other activities not listed above that present similar risks or dangers to my child.
I consent to my child’s participation in these activities. I personally assume, on my child’s behalf, all risk in connection with said activities for any harm, injury, or damages that may befall my child as a result of my child’s participation in the activities, whether foreseen or unforeseen. In consideration of my child being allowed to participate in these activities and use Faith Lutheran Church’s equipment and facilities, on behalf of my child, I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Faith Lutheran Church from any and all claims, demands, or causes of action, which are in any way connected with my child’s participation in these activities or use of Faith Lutheran Church’s equipment or facilities. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my child’s participation in these activities, I am liable for those damages and/or injuries.
In cases of emergency, I give authorization to seek medical attention at a hospital or other medical facility. I consent to the examination or treatment of my child by a physician duly licensed to practice medicine, or any health care professional duly licensed to provide health care services for medical care and services deemed necessary by Faith Lutheran Church, its agents, and employees. I give permission to the doctor or health care professional to provide any and all medical care they deem, in their professional opinion, to be necessary. I agree to pay for any and all medical expenses incurred as a result of the use of this consent. I understand that it is my obligation to inform Faith Lutheran Church of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities while on the Youth and Family Ministry Events or Activities. Should the need for any medical attention arise, Faith Lutheran Church, will attempt to contact me as soon as practical under the circumstances.
I have fully informed myself of the contents of this Parental Consent and Medical Release Form by reading it before I signed it.
As a participant, I agree to meet the following policies and expectations:
I will abstain from the use of alcohol, tobacco or drugs of any kind.
I will not use foul or offensive language.
I will wear appropriate clothing for the activity. (No skin showing from shoulders to thighs, no boxers showing, no offensive language on clothing.)
I will respect others and their property .
I understand that the person(s) in charge of the activity have the final say in any matter.
I will behave in a manner that is expected of a Christian person.
I understand that if I do not meet these expectations, my parents or guardians may be called and I may be asked to leave the activity. If this situation occurs, I understand that my parent/guardian must be present at any future activity in which I participate, until an agreement has been reached with myself, the Youth and Family Minister, and my parents/guardians.
Participant Signature:___________________________________________ Date: ________________ Parental Signature: ____________________________________________ Date: ________________ (For office use only) Form Received: ____________ Amount paid:_____________ Date:____________ Check #:____________ Balance Due: _____________ Date:____________ Check #: ____________ Additional Information: __________________________________________________________ |
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Health Insurance Information
Hospital Insurance: Yes_________ No_________ Policy Number:___________________ Insurance Company:__________________________________________________________ Hospital Preference: __________________________________________________________ Allergies:___________________________________________________________________ Medications (Include dosage and when taken): _____________________________________ Medical Concerns that would limit participation in activities: _________________________ __________________________________________________________________________ Other important Information:___________________________________________________ |
