Our Father'S Lutheran Church Health Evaluation/liability Release Form printable pdf download

Our Father’s Lutheran Church

Health Evaluation/Liability Release Form

I give permission for my child to participate in the group confirmation activities of Our Father’s Lutheran

Church. I undersigned, give permission for Our Father’s Lutheran Church chaperones, to provide for our

child;

Student’s Name _______________________________________ DOB ___________ Age ______ Grade ______

Parent/Guardian _____________________________________________

Home Address _______________________________________ City ___________________ Zip ____________

Home Phone ____________________ Work Phone _____________________Cell/Pager___________________

Insurance Carrier ___________________________________________ Group # ________________________

Carrier Address ______________________________________________ Phone # _______________________

Full Name of Insured __________________________________________ID # ___________________________

Family Doctor _______________________________________________ Phone _________________________

In an emergency, if unable to reach parent, contact:

Name ______________________________ Phone _________________Relationship to student _____________

Are your student’s immunizations current?

Yes

Date of last Tetanus Booster ___/___/___

Special Information

Medication: Does your child take either prescription or non-prescription medication on a regular basis? Yes

If yes, please state medication and reason: ________________________________________________________

Health or behavior concerns that we should be aware of: asthma, diabetes, epilepsy, ADD, ADHD etc.:

___________________________________________________________________________________________

Allergies: ____________________________Any other information: ______________________________________

This Consent Form gives permission to seek whatever medical attention is deemed necessary, and releases, Our Father’s Lutheran Church, ,

and persons associated with entity of any liability against personal losses of you/your child. Please read the following statement and sign

below.

I / We, the undersigned, are the parents, the parents having legal custody, or the legal guardians of the student named above, a minor,

and have given our consent for him / her to attend the Youth events with Our Father’s Lutheran Church. I / We understand that there

are inherent risks involved in any event, and I / we hereby release Our Father’s Lutheran Church, their employees, their agents, and

volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my /

our child’s involvement with the Event. In the event that he / she is injured while attending Confirmation activities and requires the

attention of a doctor, I / we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event

treatment is required which is a physician and/or hospital personal refuses to administer without my / our consent, I / we hereby

authorize the Pastor, Minister to Youth and Young Adults, or another adult leader designated by him / her, to give consent for me / us,

and I / we agree to hold such persons free and harmless of any claims, demands, or suits for damages arising from the giving of such

consent so long as the treatment is administered by or under the supervision of a licensed physician. I / We also acknowledge that we

will be ultimately responsible for the cost of any medical care should the cost of that medial care not be reimbursed by the health

insurance provider. Further, I / we affirm that the health insurance information provided above is accurate at this date and will, to the

best of my best knowledge, still be in force for the student named above at the time of the Event.

Parent/Guardian Signature _______________________________________ Date ________________

Note: Guns, knives, alcohol products, tobacco products, illegal drugs or other harmful substances that may be

harmful to your child or others are strictly forbidden at any Church events.

05/08

Our Father'S Lutheran Church Health Evaluation/liability Release Form