Trinity Lutheran Church and School

MEDICAL and LIABILITY FORMS

Today's Date: (i.e.; 8/01/08)

Name:
Birthdate: (i.e.; 12/01/92) Age:

Mother's/Guardian's name:
Address:

Home phone:
Cell phone:
Work phone: extension:

Father's/Guardian's name:
Address: (if different from above)

Home phone:
Cell phone:
Work phone: extension:

Family doctor: Phone:
Medical Insurance: Phone:
Policy Number:
Group Number:
Emergency Contact: Phone:
Relationship to student:

Food allergies .Y : N
If so, please list all alergies:

Medical concerns? Y N
If so, please list all concerns:

Medical Emergency/Consent Form

In case we cannot be reached during an emergency,
I (we) (parent/guardian),
being the parent or legal guardian of

give consent for emergency medical, surgical and dental treatment in a licensed medical facility by a licensed physician/dentist, and for said physician/dentist to administer whatever care is necessary as long, as the medical or surgical treatment is in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved should my child’s condition require it in my absence. I understand that in such a case, reasonable attempts would first be made to contact me, time and conditions permitting.

I impose no specific prohibitions regarding treatment unless stated here:

The undersigned shall be liable and agrees(s) to pay all costs and expenses incurred in connection with such medical/dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Parental Agreement
Date: (i.e.; 08/01/06)

Liability Release Form
Release of All claims

In consideration for being accepted by Trinity Lutheran Church & School for participation in all Trinity Lutheran Church & School Youth Activities,

I (we) (parent/guardian)

do hereby release from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and (child participant) that occur while said child is participating in all activities associated with Trinity Lutheran Church & School.

Furthermore, I (we) here by assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

Further, authorization and permission is hereby given to Trinity Lutheran Church to furnish any necessary transportation, food and lodging for this participant.

The undersigned hereby agrees to hold harmless and indemnify said church, its directors, employees, volunteers, and agents, for any liability sustained by said church as the result of participation in all youth activities at Trinity Lutheran Church & School.

Parental Agreement
Date: (i.e.; 08/01/08)
(parent/guardian or participant if 21 yrs & older)

Trip Participant Only

I have read the foregoing and understand the rules of conduct for participants and will abide by them as well as the directions of the leadership of the trip.

Participant's Agreement
Date: (i.e.; 08/01/08)