Trinity Lutheran Student Ministries Activity Release
*
First Name
*
Last Name
*
Relationship to child named below
*
Street Address
Address Line 2
*
City
*
Zip Code
*
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
*
Home Phone Number
[xxx-xxx-xxxx]
*
Cell phone number
*
Email Address
*
Today's date
[mm/dd/yyyy]
*
Child name
*
Child age
*
Child D.O.B.
[mm/dd/yyyy]
*
Allergies
*
Need to carry an epi pen?
yes
no
*
Medications
*
Activity limitations
*
Is there anything else we need to know about your child?
*
Physician Name
*
Physician phone
*
Second emergency contact
*
Second emergency contact phone
*
Permission to post your child's photo?
yes
no
*
Permission to participate in activities?
Yes
No
*
Permission to transport to and from activity?
Yes
No
*
Permission to transport for medical treatment?
Yes
No
*
I have carefully read the Trinity Lutheran Student Ministries release from libility and agree to all terms and conditions contained therein. In case of accidental injury or death I will not hold employees, volunteers, or other agents of Trinity Lutheran Church liable.
I agree
I do not agree
*
I understand this release to be in effect 12 months from the date submitted
Yes
*
Parent or guardian's full name
*
Indicates Response Required
This form created at
http://www.formsite.com/