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PERMISSION FOR A MINOR TO PARTICIPATEw/ MEDICAL INFORMATION AND AUTHORIZATION FOR TREATMENT

I HEREBY GIVE PERMISSION to the below named MINOR to participate with Lighthouse Kids at the

EVENT: Kids Friend Day - Lighthouse Christian Church, 700 Verano, Sonoma, CA 95476

DATE: July 19, 2025

IN THE CASE OF AN EMERGENCY, I hereby give permission to Lighthouse's Kids program DIRECTOR(S) or assistants to act on my behalf for said MINOR, including granting permission for evaluation and treatment of medical problems.

If I cannot be reached, I hereby give my consent to such medical treatment as deemed necessary, including permission to the PHYSICIAN and/or HOSPITAL selected to hospitalize, secure proper treatment for, order injection, anesthesia, x-ray examinations, or surgery to be rendered to my CHILD by a licensed physician or nurse.

I, the PARENT/GUARDIAN of the above named CHILD, do hereby release LIGHTHOUSE CHRISTIAN CHURCH (LCC), its agents, employees, and volunteer assistants from any liability whatsoever arising out of any injury, damage or loss which may be sustained by my MINOR during the period of involvement with LCC events.

All photography or videos of the MINOR during Lighthouse event activities remains the sole property of LCC, and LCC reserves the right to use all media obtained in any LCC audio/visual/printed materials.




First Participant's Name
First Name*
Middle Name
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Insurance Provider *
Policy #
First Participant's Signature*
Second Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Insurance Provider *
Policy #
Third Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Insurance Provider *
Policy #
Fourth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Insurance Provider *
Policy #
Fifth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Insurance Provider *
Policy #
Sixth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Insurance Provider *
Policy #
Seventh Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Insurance Provider *
Policy #
Eighth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Insurance Provider *
Policy #
Ninth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Insurance Provider *
Policy #
Tenth Participant's Name
First Name*
Middle Name
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Insurance Provider *
Policy #
Parent or Guardian's Email Address
Email
Check to receive information and updates about Lighthouse Kids events and activities.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Emergency Contact
First Name*
Last 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.


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*
Middle Name
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Insurance Provider *
Policy #
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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