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TRINITY LUTHERAN CHURCH
2018-2019 Activity Release Form

 

I consent for my child to participate in all events sponsored by Trinity Lutheran Church:

I understand that these activities and the facilities where they are conducted involve some inherent risks.  Nevertheless, I want myself (and any listed child) to have the opportunity to participate in the activities sponsored by the Church, and this Activity Release is given in exchange for that opportunity.

Waiver, Release, and Indemnification – I, individually, and in my capacity as parent, guardian, or next friend of any listed child, waive, release, indemnify, and promise not to sue the Church  and all of its constituent organizations, agents, ministers, employees, and volunteers (collectively, “Released Parties”) from all demands, claims, or liability, in law or in equity, including the Released Parties' own negligence, that have arisen or may arise from this activity, including travel associated with this activity, and that involve any damage, loss, or injury to me, my spouse, any listed child, my property, my spouse's property, or the property of any listed child.  I fully assume the risks associated with participating in this activity.  This waiver, release, indemnification, and promise not to sue does not apply to claims of criminal conduct, gross negligence, or intentional acts.

Medical - In case of medical need or injury, I understand that the Church  will make every reasonable effort to contact me (in the case of an injury to my child) or my emergency contact. In the event that I or my emergency backup contact cannot be reached, I authorize the Church  to arrange for medical services for me or for any listed child.  I will be responsible for any medical and related expenses for me or such child.  Any provider of care can rely on this Consent as authority to treat me or such child as appropriate and to bill me directly for the costs thereof.  I understand that the Church  will hold any medication for my child until needed or scheduled, at which time it is my or such child’s responsibility to inform the staff that the medication is needed.  I agree that I am responsible for communicating any relevant medical conditions pertaining to me or my child to Church  staff using the back of this form.

Photographs - I understand that the Church may take photographs of me or a listed child in the course of its activities, and I grant the Church permission to publish such photographs in a manner the Church deems appropriate.

Driving – If I am assigned to drive for any activity, I affirm that I have a valid driver's license and current auto insurance in compliance with the laws of the State of Colorado.

To revoke this agreement, I must notify the church in writing in advance of the event.

Dated: December 12, 2018

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
First Participant's Signature*
Second Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Third Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Fourth Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Fifth Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Sixth Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Seventh Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Eighth Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Ninth Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
Tenth Participant's Name

First Name*

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

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
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*

Confirm Email*
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*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Relevant Medical Information


Family physician:

Phone Number:

Medical insurance company and policy number:

Authorized medications and time they should be administered: (HS youth are responsible for keeping and administering any necessary daily meds)
May a representative of the church give your child treatment or non-prescription medicine for pain, illness, or injury?*
No
Yes

Do you or your child have any allergies, special medical conditions, emotional or social issues of which we should be aware?
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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