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Lake Sawyer Students
2019 Release Form

 

Below is a summary of the activities and events that will occur while your child participates in our Lake Sawyer Student Ministry.  The most up-to-date information for specifics on each activity, event, and the date is provided on our website www.lakesawyerchurch.org/students, social media, and email communication. If you have a question or concern about a specific event or activity, please notify the Student Ministries Pastor immediately.  This form only needs to be filled out one time, once a year, for our general youth activities listed below.  * Overnight offsite events such as camps/retreats, and mission trips will require a separate release form. ​​

Weekly Events

  • Bible studies, classes, middle school gathering - During Sunday morning services
  • Youth Group (worship, games/activities) - Sunday evenings from 6 pm to 8 pm

Summer Events

  • Summer activities and events occurring at the church or elsewhere will be provided during the month of June each year on our website www.lakesawyerchurch.org/students, and on social media. It is the parent/guardian’s responsibility to read church communication and be aware of the activities occurring and to inform the church if any of the activities or events are not permissible for your child.

Offsite Events

  • Occasional local offsite events may occur at the discretion of the Youth Pastor or Youth Leaders such as bible studies or gatherings at their homes, going to movies, sporting events, etc. These will be communicated at the time they are planned. * Overnight offsite events such as camps/retreats, and mission trips will require a separate release form.    

Questions?
Treacy Walsh, Student Ministries Pastor // twalsh@lakesawyerchurch.org
Teri Thompson, Student Ministries Admin // tthompson@lakesawyerchurch.org

Minor Participation Authorization and Consent to Emergency Medical Treatment

I hereby give my consent to have my minor child participate in all activities of LAKE SAWYER CHURCH, including onsite and offsite activities including but not limited to: home bible studies, team building activities, paintball, laser tag, inflatables, water sports (boating, tubing, skiing, etc.); playing sports (basketball, dodgeball, flag football, etc.); attending sports events; vehicle transportation to and from activities. I recognize that there are risks involved in participating in these activities and hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in these activities. To the fullest extent permitted by law, I release LAKE SAWYER CHURCH, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless LAKE SAWYER CHURCH, its trustees, officers, directors, employees, agents and representatives from any claims arising out of my minor child’s participation in the activity. Further, being the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. In the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. Should there be no activity leader available, I give permission to the attending physician to treat my minor child. I understand and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. I understand that photographs or videos of my child may be taken at these activities and I give LAKE SAWYER CHURCH full right and permission to use my child’s name, voice, signature, photograph, or likeness (as those terms are defined in RCW 63.60) in any manner and for any purpose deemed appropriate by the church.

Today's Date: July 16, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 19 years of age or older
First Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
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 be added to our e-mail communication about all youth activities and events
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 student regardless of their age and agree that they and the student 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*
I certify that I am 19 years of age or older
Parent or Guardian's Information
Student Grade *
6th grade - Middle School
7th grade - Middle School
8th grade - Middle School
9th grade - High School
10th grade - High School
11th grade - High School
12th grade - High School

Student E-mail (This is for STUDENT e-mail only).

Allergies or Medical Restrictions (leave blank if no allergies)

Dietary Restrictions (leave blank if no restrictions)
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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