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Medical and Liability Release Form

RELEASE OF ALL CLAIMS

This form needs to be completed and signed by a parent or guardian. The annual medical and liability release form is designed to provide information in the event of an emergency, permission to seek medical treatment, and parental consent of participation

Youth Information:

Youth First Name:^*

The Full name of the youth

Youth Middle Initial

Youth Last Name:^*

Youth Birthday^*

Anticipated High School Graduation Year

Youth T-Shirt Size^*

Youth Cellphone Number

Youth Email

Parent/Guardian Information:

Parent/Guardian #1 First Name^*

Parent/Guardian #1 Last Name^*

Parent/Guardian #1 Email^*

Parent/Guardian #1 Mobile Phone^*

Parent/Guardian #1 Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Parent/Guardian #2 First Name

Parent/Guardian #2 Last Name

Parent/Guardian #2 E-mail

Parent/Guardian #2 Mobile Phone

Parent/Guardian #2 Address (If Different)

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Emergency Contacts:

Please list information for two people who could be contacted in case of emergency if the parent/guardian cannot be reached (relatives, close friends). These people may provide information regarding where the parent/guardian might be reached, or they might be asked to give advice/permission for medical care. Please notify individuals that their names have been given for this purpose. These contacts aren't immediate family!

Emergency Contact First Name:^*

Emergency Contact Last Name:^*

Emergency Contact Relation to Youth:

Emergency Contact Phone Number:^*

This space is for any extra emergency contacts

Emergency Contact #2 First Name:

Emergency Contact #2 Last Name:

Emergency Contact #2 Relation to Youth:

Emergency Contact #2 Phone Number:

Doctor and Insurance Information:

Name of Primary Care Physician^*

Primary Physician Phone^*

Primary Physician Address

Address Line 1

Address Line 2

City

State or Region

Zip

Name of Insurance Company^*

Insurance Policy Number

Name of subscriber

General Health Information and History:

Please explain any checked boxes above:

Date of Last Tetanus Immunization:

Other Health Information:

Medication Info

My child takes NO medications on a routine basis.
My child may be given pain relievers (i.e. Tylenol, Motrin, etc.) as needed.
My child takes medications as follows:

Medication #1 Name:

Medication #1 Dosage:

Time for Medication #1 to be taken:

Medication #1 reason for taking:

This space is for any other medications that need to be taken

Medication Name #2:

Medication #2 Dosage:

Time to take Medication #2:

Medication #2 reason for taking:

Medication Name #3:

Medication #3 Dosage:

Time to take Medication #3:

Medication #3 reason for taking:

If there are any other medications that your child takes fill them in here with: The name of the medication, The dosage, The time in which it should be taken, and The reason for taking said medication.

MEDICAL RELEASE AUTHORIZATION BY PARENTS/GUARDIANS:

After failed attempts to contact us (me), we (I) authorize the responsible adult representing Saint Michael Lutheran Church, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home to do medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Saint Michael Lutheran Church.

We (I), the undersigned, for ourselves, our heirs, executors, and administrators, understand and agree that in consideration of the participation of my child in youth ministry events and activities, hereby agree to release discharge, and hold harmless Saint Michael Lutheran Church , its staff, officers, and agents, from all liability and loss (including court costs and attorney fees), resulting from any property damage, personal injury and bodily injury, including death, to my child, which is caused or claimed to be caused, in whole or in part, by the negligent acts or omissions of Saint Michael Lutheran Church, its staff, officers, and agents.

Consent is also given to the photographing of our (my) child and the recording of his/her voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. Further consent is given to the reproduction and/or authorization by Saint Michael Lutheran Church to reproduce and use said photographs and recordings of our (my) child’s voice, for use in all domestic and foreign markets. It is understood that the term “photograph” as used herein encompasses both still photographs and motion picture footage.

SIGNATURE OF PARENT/GUARDIAN (.jpg):^*

SIGNATURE OF PARENT/GUARDIAN (.jpg):

Today's Date:

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Saint Michael Lutheran Church

Church Office Hours:

Church Location & Address:

Telephone & Fax:

Verification

Medical and Liability Release Form

RELEASE OF ALL CLAIMS

This form needs to be completed and signed by a parent or guardian. The annual medical and liability release form is designed to provide information in the event of an emergency, permission to seek medical treatment, and parental consent of participation

Youth Information:

Parent/Guardian Information:

Emergency Contacts:

This space is for any extra emergency contacts

Doctor and Insurance Information:

General Health Information and History:

This space is for any other medications that need to be taken

MEDICAL RELEASE AUTHORIZATION BY PARENTS/GUARDIANS: