St paul lutheran church

St Paul Lutheran Church
Release of Liability Form
181 S Santa Clara New Braunfels, TX 78130 Contact Information
Dependent Name
Address
City State Zip
Home Phone #
Date of Birth
Parent Information
Parent/Guardian
Work Phone
Cell Phone
Doctor's Name
Office Phone
Emergency Contact Information (if parent/guardian cannot be reached)
Contact Name & Phone #
Address
City State Zip
Work Phone
Hospital and Insurance Information
Hospital Preference
Insurance Info (Attach copy of front & back of card)
Insurance Company
Group #
Member #
Health History
Please list any Special Medical Conditions
Date of last Tetanus Shot
Medications to be taken (list with directions)
Medication Name
I hereby request and give permission for the staff of St Paul Lutheran Church and their volunteers to administer the
medications listed above and over the counter medicine to the student named on this form. I understand it is my
responsibility to provide the prescription medication. I also understand that all medications must be provided in the original
pharmacy containers. I understand my child is responsible for reporting to the staff and volunteers at appropriate times to
receive their medications.
Parent Signature_______________________________ Date _____________________________________
Medication Allergies
Food Allergies
(Please list all allergies to medicines) I give permission for my child to receive (Please check the items that are approved) Transportation Release (applies to students only) Discipline Release (applies to students only) I give permission for my youth to be transported to and from church In the event of misconduct, I authorize the staff and volunteers to send sponsored activities in a church, rental, or private vehicle. Insurance Release (applies to all traveling) Personal Belongings Release (applies to all traveling) I realize the church insurance begins where the individual health and I realize that the church, its staff and volunteers are not responsible for accident policy terminates. It is only valid when all other insurance has been extended to its limits. I also understand that there is no assurance that any particular situation or event will be covered for loss. General Release I hereby give consent in advance to the designated Youth Leaders and the volunteers of St Paul Lutheran Church and to the physicians or hospitals selected by them to render first aid treatment or deny treatment as in their judgment is reasonably necessary, including, but not limited to, hospitalization, diagnosis including taking specimens, and x-rays, giving blood transfusions, and medications, anesthesia, and surgery for my dependent listed above. I understand that the Youth Leaders of St Paul Lutheran Church will attempt to contact me before securing treatment, but that this consent is given in case I am not available in an emergency. I release all Youth Leaders and staff affiliated with St Paul's from any and all claims, loss, cost, damage, or expense arising out of or from any accident or other occurrences causing injury to an person or property. Parent Signature ______________________________ Date ______________________________________ This form must be notarized in order for your youth to travel and participate in the youth activities for St Paul Lutheran Church. Parent Signature _______________________ Date ______________________________ On _________________ before me, ___________________________ personally appeared _______________________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal. Notary Signature ______________________ Date _______________________________

Source: http://splchurch.org/wp-content/uploads/2013/06/New-Youth-Participation-Form-notarized-2012-2013.pdf