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ATTENTION ALL ADULTS

Please complete and return this form to the church, attention youth ministry.  The form will be kept on file during the 2018-2019 youth ministry program year (September 2018 – August 2019).  Please update any change in telephone number/contact numbers prior to any church sponsored trips.  All participants must have a completed form on file in order to participate on any retreat, mission trip, or event involving leaving the church premises.

MEDICAL & LIABILITY RELEASE FORM

Saint Luke’s Presbyterian Church • 1978 Mt. Vernon Rd • Dunwoody, GA  30338

FAX:  770-393-3278 • Phone:  770-393-1424

This forms gives the group leaders authorization to secure medical aid for you should it be necessary.

I hereby authorize any hospital, clinic, physician, doctor, nurse or technician to furnish me any medical care treatment necessary as a result of injuries sustained or other emergency medical treatment as the circumstances require while being transported from and back to the church, and while at the place of destination. I hereby authorize a representative of the Saint Luke’s Presbyterian Church to retain or acquire said medical care and treatment on my behalf if I am unable to make that decision. I agree not to hold such a person responsible for any damages rising from the giving of such consent.

Today's Date: December 15, 2018

First Participant's Name

First Name*

Last Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

First Participant's Signature*
Second Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Third Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Fourth Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Fifth Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Sixth Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Seventh Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Eighth Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Ninth Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

Tenth Participant's Name

First Name*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy 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*

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

Please list any health problems or allergies:

Please list any and all medications (name, dosage, prescribing doctor):

REGULAR DOCTOR: *

PHONE: *

I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.

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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