High School Camp Medical Release Form & Permission to Attend
High School Camp at Luther Glen - February 18-20, 2017
Medical Release and Permission to Attend Form
Your Email Address
Special needs, medical allergies, chronic illnesses or other conditions:
Father’s Cell Number
Father’s Phone Number (work or home)
Mother’s Cell Number
Mother’s Phone Number (work or home)
Emergency Contact Name and Relationship (Other Than Parent)
Doctor’s Phone Number
Policy Number/Group ID Number/ID Number
We normally us email as our primary communication to announce event details.
PERMISSION TO ATTEND AND TRAVEL
By clicking Submit, being either a parent with legal custody or the legal guardian of the minor whose name appears above, hereby authorizes the student named about to participate in various events and/or trips with Mission Lutheran Church (MLC) under the supervision of paid and/or volunteer leaders through September 1, 2017, and to be recorded and photographed for promotional purposes (including website postings). I further agree to personally pick up my minor promptly if, at the sole discretion of the leader responsible for the event, the minor is ill or a disruption to the mission of MLC Youth Ministries. NOTE: If you desire to limit your child’s participation in an event, please submit your wishes in writing to Mission Lutheran Church prior to the event.
Being an adult participant or a parent with legal custody or the legal guardian of the minor whose name appears above, hereby authorizes any adult person (paid or volunteer) at Mission Lutheran Church of Laguna Niguel, California into whose care the minor has been entrusted (or with whom I am traveling if an adult) to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, dental diagnosis or treatment, and/or hospital care to be rendered to the minor (or myself if an adult) under the general or special supervision of any member of the medical/dental staff and emergency room staff licensed under the provisions of the Medical Practice Act or Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health.
It is understood that efforts shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to California Civil Code section 25.8. If a personal physician is listed, every effort will be made to contact such physician. The signing of this release only gives the Church and agents thereof, the right to consent for treatment of minors/adults. It does not release signee of liability from medical cost arising from said treatment. It is understood that the releases provide no medical insurance for such treatment. I further agree to be liable for any expenses related to treatment performed under this release. This release shall remain in effect through September 1, 2017. Please inform Mission Lutheran Church in writing of any change in the information presented.
One Student (Add $149.00)
in the box to the right »
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