EVANGER LUTHERAN CHURCH YOUTH

PERMISSION AND MEDICAL RELEASE

SEPTEMBER 2009 through AUGUST 2010 
 

Completion and signature of this form by a parent or legal guardian and is required before participation in youth activities. 

To be signed by participating student:

PARTICIPANT’S CONTRACT

I,___________________________, WILL CONDUCT MYSELF as a Christian witness to all youth events that are sponsored by Evanger Lutheran.  I realize I am participating in Christian fellowship to get to know fellow youth group members, Jesus Christ, and to have fun!!  I promise to obey the rules set forth by the adult leaders and any other officials that may be involved.  If I fail to do so, I understand that I may be sent home at MY expense.  If should such an incident occur, I am aware that my parents will be telephoned and informed of the circumstances and appropriate discipline procedures will be discussed and carried out.

 

Participant:

Name:  

Sex:______  Age:_____ Birthdate: 

Parents’  Name   Phone # 

 

Address:  

City:  State:  Zip:  

Evanger kid:  Friend of Evanger kid:  
 

Emergency Contacts:

Primary Contact:  Relation to Youth: 

 

Daytime Phone:  Evening Phone:  

Backup Contact:  Relation to Youth:  

Daytime Phone:  Evening Phone:  
 

Insurance Policy:

Policy Holder’s Name:  Date of Birth:  

Relation to Youth:  

Address:  Phone #:  

Insurance Company:  

Insurance Policy #:  Plan #: 

 

Permission – parent signature required

I, (print name of parent) ______________________, am the parent or legal guardian of (name of youth) _______________________, and I am informed of the activities offered by Evanger Lutheran Church, located at 33504 660^th Avenue, Sargeant, MN.  As the parent or legal guardian of my child, I hereby consent for my child to attend and participate in all activities provided by and/or attended by Evanger Lutheran Church. 

Additional:  My child is to be excluded from the following activities: 

Evanger may have appropriate pictures or video taken at events that may be used in the church newsletter, the church website or group settings.  Please indicate by circling Yes or No if you give your permission for use of such pictures or videos here:  Yes   No 

Signature of parent:  _______________________________ 

Medical Treatment Consent – parent signature required:

I consent to examination and treatment of my child by a qualified physician and/or hospital emergency room.  I also understand that neither Evanger Lutheran Church, any sponsoring organization nor anyone connected with Evanger Lutheran Church nor any sponsoring organization will assume any responsibility for accidents or sickness incurred by my child while at their scheduled activity.  I agree to assume sole responsibility for payment of any and all medical, dental, or other expenses incurred as a result of such sickness and/or injury. 

Parent’s Signature:________________________________    Date:_________ 
 

Medical History and Immunization Dates:

Does the youth have any of the following?  (If yes, please explain): 

Drug allergies:  Food allergies:  

Allergies to insect bites:  Special dietary needs:  

Asthma:  Frequent headaches, dizziness or seizures:  

Other health problems or limitation of activities:  

Medications the youth is taking:  

Last Tetanus (DPT, YT or TD)  
 

***Please note:  Our staff cannot administer any medications, prescription or non-prescription to youth.  This includes over-the-counter medicines for minor headaches or pains.  Youth leaders may keep medications in their possession for the youth to administer themselves. 
 

Physician’s Information:

Physician’s Name:  

Address:  Telephone #