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PERMISSION FOR A MINOR TO PARTICIPATEw/ MEDICAL INFORMATION AND AUTHORIZATION FOR TREATMENT

I HEREBY GIVE PERMISSION to the above named MINOR to travel and/or participate with Lighthouse Youth at the

EVENT: Radical Reality Summer Camp (Donnie Moore), Richardson Springs, CA
DATE: Monday-Friday, July 23-27, 2018

IN THE CASE OF AN EMERGENCY, I hereby give permission to Lighthouse's program DIRECTOR(S) or assistants to act on my behalf for said MINOR, including granting permission for evaluation and treatment of medical problems.

If I cannot be reached, I hereby give my consent to such medical treatment as deemed necessary, including permission to the PHYSICIAN and/or HOSPITAL selected to hospitalize, secure proper treatment for, order injection, anesthesia, x-ray examinations, or surgery to be rendered to my CHILD by a licensed physician or nurse.

I, the PARENT/GUARDIAN of the above named CHILD, do hereby release LIGHTHOUSE CHRISTIAN CHURCH (LCC), its agents, employees, and volunteer assistants from any liability whatsoever arising out of any injury, damage or loss which may be sustained by my MINOR during the period of involvement with LCC events.

All photography or videos of the MINOR during Lighthouse event activities remains the sole property of LCC, and LCC reserves the right to use all media obtained in any LCC audio/visual/printed materials.

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Check to receive information and updates about Lighthouse Youth events and activities.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Insurance Provider *

Policy #
Polio Vaccination*
No
Yes

Last Tetanus Shot

Allergies to Medications

Daily Medication(s) and Dosage

Restrictions (Physical Activity/Medical)
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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