EmailMe Form - Spark Middle School Lock In

Name

First Last

Address

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

Gender

Grade

Birthday

Age at Event

Does the camper have any known allergies?

Yes

No

Please specify allergies

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

Does the participant have any special needs or medical history?

Is the participant on regular medication? If so, please list the drugs, dosages, and any instructions:

(Please note that no drugs are to be brought to youth events other than those listed above)

Participant’s Physician’s Name

Hospital/Clinic and Address

Phone Number

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

Emergency Contact Information

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

Name

First Last

Relationship

Phone Number

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

Email

My student has permission to participate in the:

Middle School Lock In

RELEASE OF ALL CLAIMS

In consideration of being accepted by Saint Luke Lutheran Church for participation in youth ministry events,
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 Lutheran Church, 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 synod 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, share the 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) give permission for the participant to receive over the counter medication such as Tylenol, ibuprofen, antidiahhreal medication, antibacterial ointment, throat lozenges, eye wash solution, and the like.
I (we) also grant Saint Luke Lutheran 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