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Redeemer Lutheran Church
7755 Greenstone Trail
Fort Collins, Colorado 80525 

 

Date signed: June 2, 2025

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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:*
Additional Information
Please include a copy of your insurance card below *
  
Valid file types: JPG, GIF, PNG, and PDF
Emergency Contact
First Name*
Last 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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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*
Date of Birth
Parent or Guardian's Information
Home Phone
Mobile Number
Age of Participant
Grade of Student

Activity: NextGen Students Activities for June 2022 - May 2023 

Functions and Activities

I / We herby, give permission for myself/our student listed above to participate in the listed activity. I / We acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death.
I / We hereby give our permission for the representatives of Redeemer to administer necessary First Aid and Medical aid to myself/our student when seen appropriate. I / We realize that every effort will be made to contact the emergency contact on this form for treatment. If the leaders of Redeemer Lutheran Church cannot reach emergency contact, I / We give them permission to admit myself/our student into the care facility at that location. I / We release the agents of Redeemer Lutheran Church from any claim that myself/our student may have or that I / We may have against them as a result of injury or illness incurred during the course of participation in the activities.
I / We hereby give permission for myself/our child to ride in any vehicle designated by the adult in whose care myself/the minor has been entrusted while attending and participating in activities sponsored by Redeemer Lutheran Church.
I give Redeemer Lutheran Church permission to publish any pictures taken of myself/my student in any location by Redeemer Lutheran Church.

If there are any past medical surgeries or major injuries please list them below. Please also list current medications that the participant is using with specific instructions, along with any allergies. 

Surgeries / Major Injuries:
Current Medications:
Allergies (including food):

Insurance information: 

Company
Policy Number
Phone number
Insured Party
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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