Medical, Transportation, and Photo Consent Form 2024

Student Information

Student's Name

Date of Birth

Medical conditions and allergies

History of asthma?

yes no

History of seizures/ loss of consciousness?

yes no

History of heart problems?

yes no

Any other needs?

Consent to take and/or use photos at the event?

Yes No

Consent for adults of Our Saviour's to transport your child for event purposes?

Yes No

Emergency Contact

Emergency Contact Name

Emergency Contact Phone number

Parent/guardian information

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Phone Number

I give my consent in advance to the leaders of Our Saviour's Evangelical Lutheran Church and to the physicians/hospital selected by them to render emergency treatment or transportation as in their judgement is reasonably necessary for my dependent listed above. I understand that the leader of this activity will attempt to contact me before securing medical treatment, but that this consent is given to and from church sponsored events in private vehicles. I specially release the leadership of this activity and member of Our Saviour's Evangelical Lutheran Church from any and all claims, loss, cost, damage or expense arising out of or from any accident or other occurrences causing injury to any person or property.

Type your full name to give consent

Date

Medical, Transportation, and Photo Consent Form 2024

Description

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