Holy cross lutheran church

Valid through May 31, 2014
PLEASE READ CAREFULLY AND FILL OUT COMPLETELY BEFORE SIGNING
Emergency contact in case we cannot contact Parent/Guardian:
Name
(Please attach a copy of insurance card, back and front)
Family Physician’s Name

Emergency & Health Information
Does youth have…(if “yes” please explain) _____yes _____no Food or environmental allergies? Is youth subject to…(if “yes” please explain) _____yes _____no Fainting? Does youth have allergic or serious reactions to…(if “yes” please explain) _____yes _____no Bee sting? _____yes _____no Poison Ivy, oak, sumac? Please indicate ANYTHING else which leaders should know to avoid or help deal with your youth’s health including any medications or medical conditions/restrictions to physical activity.
You have my permission to give my youth:
_____yes _____no Robitussin (cough medicine)
_____yes _____no Dramamine (for motion sickness) _____yes _____no acetaminophen (Tylenol) _____yes _____no Rolaids, Mylanta (antacid) _____yes _____no diphenhydramine (Benadryl) _____yes _____no ibuprofen (Advil, Motrin) _____yes _____no topical antibiotic ointment _____yes _____no topical cortisone ointment _____yes _____no Solarcaine spray/lotion/ointment Other medications with dosage/schedule to be taken: (All medications must be sent in its original container) EMERGENCY PROCEDURE: IN THE EVENT OF ANY EMERGENCY, HOLY CROSS LUTHERAN
CHURCH STAFF WORKERS WILL MAKE AN ASSERTIVE EFFORT TO FIRST CONTACT
PARENT/GUARDIAN/DOCTOR! In case they are unable to do so, I GIVE THE FOLLOWING
AUTHORIZATIONS ON BEHALF OF MY SON OR DAUGHTER;
_____yes _____no 1. With my signature, I hereby authorize First Aid by Holy Cross Lutheran staff workers.
_____yes _____no 2. With my signature, I hereby authorize emergency medical care by hospital or
emergency care doctors and/or medical staff selected by Holy Cross Lutheran _____yes _____no 3. With my signature, I hereby authorize doctor(s) selected by Holy Cross Lutheran staff workers to hospitalize, secure treatment for, and to order all necessary emergency medical treatment including, injection, x-ray or other diagnostic examination, anesthesia, blood transfusions, or surgery. I further agree to pay all charges for the emergency medical or hospital care or treatment. If parent/guardian has answered “NO” to any of the above, parent/guardian must indicate the procedure to be followed in the event youth workers are unable to contact parent/guardian/designee
Permission for Swimming and Water Related Recreational Activities
_____yes _____no You have my permission to allow my son or daughter to (a) swim in a swimming pool/lake, and/or (b)
participate in other water related activities such as boating/canoeing. I understand that a life guard will not be on duty
during these activities.

Permission for Publishing of Youth Likeness in Pictures and Video
______yes ______no We understand that my daughter or son’s likeness, selected by a staff member at Holy Cross
Lutheran Church, could be published on the World Wide Web, a part of the Internet, or posted on bulletin boards. NO
LAST NAME, HOME ADDRESS, OR PHONE NUMBERS WILL APPEAR WITH THE PICTURES. We grant permission
for posting of pictures and video as described above indefinitely or until I request removal.

Release Statement
I acknowledge that there is the possibility of bodily injury whenever youth travel and participate in recreational activities. I hereby release Holy Cross Lutheran Church, its staff, all voluntary assistants, and their heirs from all liability for injuries that my dependent minor or I may receive while traveling, participating in, and returning from the activity. I further understand that by signing this document that I am releasing my rights to seek recovery from Holy Cross Lutheran Church, Holy Cross Lutheran Church staff workers, voluntary assistants, and their respective successors and heirs. I acknowledge that this total waiver shall operate to prevent my spouse, or my heirs from pursuing any such action arising out of a Holy Cross Lutheran Church youth activity. I grant my permission to ______________________________________ to participate in Holy Cross Lutheran Church youth activities. To the best of my knowledge he/she is in good health and capable of
extended physical activities.
By signing this form, I acknowledge that I am the parent or legal guardian of the youth and have read
this form, understand it, and agree with its entire content. I further agree to notify Holy Cross Lutheran
Church in writing if I become aware that any of the above permissions or information about my son or
daughter has changed

Signature

Youth’s Covenant for Participation
I agree to participate in the functions and activities of Holy Cross Lutheran Church, to cooperate with the leaders and
other young people, and to conduct myself as a Christian. I promise to respect God, respect myself, respect other
persons, and respect property. I understand that my continued participation in church activities depends on my support of
this agreement.
Signature

Source: http://holycrosslutheran.net/wp-content/uploads/2013/05/2013Youth_Ministry_Release.pdf