EmailMe Form - Spark: Confirmation Registration

Parent/Guardian Name

First Last

Relationship

Parent/Guardian Name

First Last

Relationship

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Primary Phone

### - ### - ####

Type

Primary Email

Student Information

Name

First Last

Student Cell Phone

### - ### - ####

Student Email

Gender

Birthday

Grade

Does the child have any known allergies?

Yes

No

Please specify allergies

Are there any over the counter medications the child can not receive?

Does the child have any special needs or medical concerns?

Emergency Contact Information

Please enter the name of who should be contacted in the case of an emergency.

Name

First Last

Relationship

Phone Number 1

### - ### - ####

Phone Number 2

### - ### - ####

Name

First Last

Relationship

Phone Number 1

### - ### - ####

Phone Number 2

### - ### - ####

I give permission to the staff/volunteers of Saint Luke to:

Administer basic first aid to my child

Administer Benadryl to my child for allergic reactions

Seek emergency medical treatment for my child if emergency contacts cannot be reached

contact my child directly to encourage/strengthen their participation in Spark Student Ministries

My student has permission to leave class independently:

Yes, they may leave at the end of class without a parent present.

No, I'd prefer a parent/guardian to pick them up.

RELEASE OF ALL CLAIMS

In consideration of being accepted by Saint Luke Evangelical Lutheran Church for participation in youth activities, I (we) do for myself (ourselves) and on behalf of my child/participant do hereby release, forever discharge, and agree to forever hold harmless Saint Luke, the employees, and agents thereof, from any and all liability, claims and demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by me or my child/participant resulting from said child's participation in the church sponsored youth events, including travel, recreation and all associated activities. Further, I (we) (and on behalf of our child/participant under 18 years of age) hereby assume all risk of said personal injury, sickness, death, damage and expenses as a result of participation as above set forth. I also understand that staff and volunteers are not responsible for the administration of prescribed medication and I (we) have made private arrangements for any medication taken on a daily schedule by my child/participant. I (we) am (are) the parent(s) or legal guardian(s) of this participant, and herby grant my (our) permission for him/her to participate fully in said youth events, and give my (our) permission to take said participant to a doctor or hospital, sharethe above medical information and authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and assume responsibility of all medical bills incurred by my child. I (we) also grant Saint Luke Church unrestricted rights to use, alter, and reproduce any images (still and video) from the event, in any medium without compensation.

Name

First Last

Signature

Clear

Date

MM / DD / YYYY