First Parent/Guardian's Name
*
First Name
Last Name
First Parent/Guardian's Email Address
*
First Parent/Guardian's Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
First Parent/Guardian's Phone
*
(###)
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Second Parent/Guardian's Name
*
First Name
Last Name
Second Parent/Guardian's Email Address
Second Parent/Guardian's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Second Parent/Guardian's Phone Number
(###)
###
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Permission to Treat a Minor and Liability Release
*
We authorize St. Paul Lutheran Church staff, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or said hospital.
The parent or legal guardian shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
The parents or legal guardian does also hereby give permission for our(my) child to ride in any vehicle, to participate in any off-site function, designed by the event leader in whose care the minor has been entrusted while attending and participating in activities sponsored by St. Paul Lutheran Church, Treynor, Iowa. The undersigned gives permission for any approved church function.
RELEASE OF LIABILITY
I hereby acknowledge that during an approved church function, my child will be participating in activities under the arrangement of St. Paul Lutheran Church, Treynor, Iowa, and its Youth and Family Ministries. During these events, certain risks and danger, inherent or otherwise, may occur, including, but not limited to accident or illness.
In consideration of, and as part payment for, the right to participate in approved church functions and activities, I have and do hereby assume all risks on behalf of the above named student. I will hold St. Paul Lutheran Church, Treynor, Iowa, harmless from any and all causes of action, debt, claims, demands, judgment executions, cost, loss of services, expenses, compensation and any and all other claims of damages whatsoever, including but not limited to, those arising from accommodations, any acts or omissions of St. Paul Lutheran Church, or any other person connected with St. Paul Lutheran Church.
Photo/Video Permision
*
Texting or calling permission
*
First Child's Name
*
First Name
Last Name
First Child's Birthday
*
MM
DD
YYYY
First Child's Grade
*
Cell Phone Number (if applicable)
(###)
###
####
Please list any special needs, allergies, or medications staff should be aware of.
Second Child's Name
First Name
Last Name
Second Child's Birthday
MM
DD
YYYY
Second Child's Grade
Cell Phone Number (if applicable)
(###)
###
####
Please list any special needs, allergies, or medications staff should be aware of.
Third Child's Name
First Name
Last Name
Third Child's Birthday
MM
DD
YYYY
Third Child's Grade
Cell Phone Number (if applicable)
(###)
###
####
Please list any special needs, allergies, or medications staff should be aware of.
