Saint Michael Lutheran Church

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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:

The Full name of the youth

Parent/Guardian Information:

Address Line 1
Address Line 2
City
State or Region
Country
Zip
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!

This space is for any extra emergency contacts

Doctor and Insurance Information:

Address Line 1
Address Line 2
City
State or Region
Zip

General Health Information and History:

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


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.

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