By completing and signing this form, you give following consent, release, and permission:

Parental Consent

I give my consent for my child to attend and participate in all the various programs and activities that St. Paul’s Lutheran Church & School ministries sponsor, under the supervision of the adult advisors. I hereby Exempt and release St. Paul’s Lutheran Church & School from any and all Liability from of any damage, loss or injury to the individual or property while they are participating in any of the activities.

Medical Release

I give my permission for a representative of St. Paul’s Lutheran Church & School to authorize medical treatment and seek emergency medical, surgery or dental care if necessary for my child as considered advisable or necessary in the judgment of an emergency medical professional or attending physician. I give the adult advisors /leaders the authority to act on my behalf with respect to my child’s health and safety while attending the events and understand that I or the emergency contact listed below will be contacted as soon as possible should need arise. I accept full responsibility for expenses for medical treatment for my child.

Transportation/Photos

I also hereby give permission for 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 St. Paul’s Lutheran Church and School. I also recognize that photographs and video images of events are used for publicity materials such as the church website, newspapers and newsletters and I hereby grant permission for photo/video images of my child to be taken and used for such purposes.

This consent is effective through August 31, 2018.

ALL FIELDS ARE REQUIRED

Participants Name

Address

City

State

Zip

Current Grade

Date of Birth
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Home Phone

Mom's Cell Phone

Dad's Cell Phone

Student's Cell Phone

Checking this box indicates your approval of communication with Shannon and your youth via this phone # (e.g., text).
YesNo

Family Email

Student Email

Insurance Policy Name

Insurance Policy #

List any allergies or specific medical issues

IN CASE OF EMERGENCY:

Name

Phone

Relationship to participant

Electronic Signature of Parent or Guardian

Date:
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