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Complete and submit this form to acknowledge your child's participation in Summer Bible Blast! and/or the Bethel nursery.

Participation and Medical Consent

My Child has permission to take part in all children's activities (e.g., Summer Bible Blast! and Bethel Nursery) activities at Bethel Lutheran Church (Church).

I Agree

I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my child is injured or becomes ill. I authorize the staff, volunteers, hospitals, licensed medical or dental providers and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x­ ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

I Agree
 

Release of Responsibility

I understand that Bethel Lutheran Church, its pastors, staff, and adult volunteers will not be responsible for medical expenses incurred. I further agree to notify the staff in writing of any health changes that would restrict my child's participation in any normal activity that they do.

I Agree
 

I further absolve Bethel Lutheran Church, its pastors, staff, and adult volunteers from liability in acting on my behalf in this regard so long as they are not grossly negligent. If a dispute over any claim arises, I agree to resolve the matter through a mutually acceptable arbitration process.

I Agree
 

Photo and Video Release

I give permission for photos, video, and electronic images to be taken of me or my child and used by the Church for promotional purposes without compensation, inspection or approval. 

I Agree
 

Participant Compliance

Should my child not follow the stated (verbal and written) activity guidelines, I may be required to pick up my child at any time during the course of the activity. I will also bear any cost for additional transportation if my child leaves or is asked to leave the activity before completion.

I Agree
 

First Parent/Guardian's Name
First Name*
Last Name*
First Parent/Guardian's Age Acknowledgment*
First Parent/Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Parent/Guardian's Signature*
Second Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Third Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Fourth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Fifth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Sixth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Seventh Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Eighth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Ninth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Tenth Parent/Guardian's Name
First Name*
Last Name*
Parent/Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
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*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
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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