Medical Release and Liability Form
for the activities of
Trinity Lutheran Youth Group
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I/we the undersigned
parent(s)/guardian(s) of __________________ ,a minor, do hereby authorize my/our
child's group leader, youth counselor, or agent of Trinity Lutheran Church
-Consent to medical, surgical, and dental care for such a minor child.
-Consent to any diagnostic test, medical, surgical, or dental procedure or treatment as may be considered necessary by the physician, surgeon, dentist, or other health care personal providing care for such a minor child and on my/our behalf to employ physicians, surgeons, dentists, nurses, and other health care personal as may be deemed necessary for such minor child, admit such facility for examination, treatment, surgery, or care and sign all necessary consents and authorizations.
I/We understand that an attempt will be made to notify the parent(s)/guardian(s) first. If parent(s)/guardian(s) are not available, however, the above authorizations will take place.
It is understood that this authorization is given in advance of the occurrence of any condition or situation which would necessitate any such medical, surgical, or dental care being required but is given to provide authority to obtain such care if it should be required.
We further release Trinity Lutheran Church and any members of its governing boards and committees, pastors, employee's, staff counselors, and volunteers, acting on behalf of any of the above, from any and all liability, claims, suits, causes of action and demands, at law or in equity, and however arising, for personal injuries and damages which may be incurred by our child and/or ourselves while such child attends, participates in, or travels to and from, any youth activities sponsored by, or affiliated with the youth ministry program of Trinity Lutheran Church.
If conduct of the participant warrants them to be excused from participation in any event, we/I assume all responsibility for disciplinary action and picking up my child upon being notified by the adult supervisor in charge.
Please check the following which apply:
____I/We give my/our permission for my child to participate in all future activities unless otherwise specified.
This form will be kept with the leader during all activities.
____I/We authorize my/our child to ride home with only the following:
____I/We authorize my/our child to drive to and from church
activities and carry their
Emergency Medical Information and
Medical/Dental Treatment of Minor
City_______________________________________ State________________ Zip_________
Age_______ Birth Date_______________________ Phone__________________
Relationship_________________________________ Work Phone_______________
Cell/Pager Phone_____________________________ Home Phone_______________
Emergency Contact Name________________________________________________
Health Insurance Company___________________________________
Insurance Policy of Group Number_____________________________
Insurance Company Phone Number____________________________
Physician's Name________________________ Phone_____________
Dentist's Name__________________________ Phone_____________
Optometrist's Name______________________ Phone_____________
Orthodontist's Name______________________ Phone_____________
Does participant have/subject to/reaction to: (if yes please explain)
|___||___||Had any serious illnesses or surgeries within the past ten years?_____________________|
|___||___||Have any condition that would prevent him/her from participating in any of the groups activities?|
|___||___||Are any drugs ineffective for treatment?___________________|
|___||___||Is the participant diabetic?______________________________|
|___||___||Does the participant have any sight or hearing impairment?__________________________|
|___||___||Does the participant wear contact lenses?___________________|
|___||___||Is participant on any regular prescription drugs?|
|Please list and describe dosage________________________________________________|
|___||___||Does your child wear a medic alert bracelet?|
Date of last tetanus
Please indicate anything else that the leaders should know to help avoid or deal with any situation that might arise:_____________________________________________________________________________
I/We fully understand the consequences of the foregoing statements and sign the AUTHORIZATION FOR MEDICAL/DENTAL TREATMENT OF MINOR knowingly, freely, and willingly. (one signature must appear below or your child will not be permitted to attend)
|I/We authorize agents of Trinity Lutheran Church to supply the following over the counter medication to my child.||_______________________________________________|