2024-25 Medical Release Consent Form • Joy Lutheran Church

Student Information

Student Name *

Date of Birth *

Student Home Address *

Student Cellphone (if applicable)

Student Year in School *

Parent/Guardian Information

Mother/Legal Guardian Name *

Cell Phone

Home Phone

Work Phone

Father/Legal Guardian Name *

Cell Phone

Home Phone

Work Phone

Alternative Emergency Contact Name

Cell Phone

Home Phone

Work Phone

Medical Information

Physician Name

Office Phone

Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken.

Check the following areas of concern for this student.

Describe Other:

Does your child suffer from, or has ever experienced, or is being treated currently for any of the following (list any chronic illnesses here):

Describe Other:

Date of last tetanus shot

Please list any current medications your child is taking, as well as instructions of dosage, etc.

Should your childs activities be restricted for any reason? Please explain:

Please list and/or explain any major illnesses or any other medical issues we might encounter or need to be aware of.

The student listed in this document has my permision to attend all youth activities sponsored by Joy Lutheran Church (hereinafter the “Church”).

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.

I/We, the undersigned, have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, it pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she/they is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/We agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should he/she/they become ill or if deemed necessary by the student ministries staff member.

I consent to the use of any photograph or video of my child in future Joy Lutheran Church publications, videos, or web site pictures. The Church will never reveal the identity of a minor child in any publication.

ELECTRONIC SIGNATURE ACKNOWLEDGEMENT AND CONSENT FORM

I, parent/legal guardian, agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

First/Last Name *

Todays Date *