release

Trinity Lutheran Student Ministries Activity Release

* First Name

* Last Name

* Relationship to child named below

* Street Address

Address Line 2

* City

* Zip Code

* State

* 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

* 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

* Permission to participate in activities?

Yes

* Permission to transport to and from activity?

Yes

* Permission to transport for medical treatment?

Yes

* 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