Creator Lutheran Church Medical Release Form 2023 (valid through June 2024)

Youth Name

Parent/Guardian name

This address will receive a confirmation email

Home Phone

Parent Cell Phone

Address

I declare that I am the parent/guardian of the above mentioned youth. In the event of an emergency or if any medical/surgical care becomes necessary for my child, and I cannot be reached, I consent and appoint Creator Lutheran Church, its Pastor, Youth Director, Youth Group Leader, and/or acting representatives to aurthorize medical attention as recommended by a licensed physician or clinic, for any injury received while participating in a Creator Lutheran Church Youth activity. I agree to pay all medical costs involved in such emergency treatment. I release and discharge Creator Lutheran Church and/or its representatives involved in the event from any liability whatsoever in exercising this permission. To the best of my knowledge, my child is in good health and is in sufficiently good physical condition to engage in reasonable athletic events or activities included in the outings. I give complete and unqualified permission for participation in outings and activities.

Yes. Authorized No

Family Physician

Insurance Company

Policy Number

Member's Name

Allergies? Please explain completey and let us know what steps we will need to take to avoid reaction.

Current Medications that we need to be aware of?

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship to participant

I give my permission for Creator Lutheran Church to publish photographs of my child for promotional purposes in print and on the internet (no names will be published).

Yes No

Creator Lutheran Church Medical Release Form 2023 (valid through June 2024)

Description

Please Fix the Following