Purpose of Form Submission * Household name Birth Date * Full Address * Home Phone Minor's Cell/Mobile Phone (if applicable) Primary Parental Contact Name * Secondary Parental Contact Name Primary Parental Contact Cell Phone * Secondary Parental Contact Cell Phone Primary Parental Contact Work Phone Secondary Parental Contact Work Phone Step Parent (if applicable) Others Authorized To PIck-up Household Email Address * Minor's Email Address School Grade School Name Christian Conduct
Just as Jesus did, I will treat other people and myself with respect and love. I will not, for any reason, hit or abuse anyone verbally or physically. I will not use any kind of illegal drugs, alcohol, or weapons, including but not limited to knives, firearms, or fireworks at the Lutheran Church of the Holy Spirit and church sponsored activities. The use of tobacco products is prohibited by minors and only permitted outside in designated areas by adults. Remember, even second hand smoke is harmful.
Cell phones will be permitted for emergency use only. If I or my child brings any electronic device, I release The Lutheran Church of the Holy Spirit, Emmaus, PA from any or all responsibility or damage of said electronic devices.
Photo Permission For Events (Check all for which you give permission.) In an emergency please contact: Name * Relationship * Emergency Phone Nr. * Insurance Information
Accident and sickness insurance is not provided by Lutheran Church of the Holy Spirit. Families are asked to use their family policy as primary carrier to satisfy all claims.
A copy of both sides of your medical insurance card is required for participation. If your insurance information changes, it is your responsibility to submit a new copy of your medical insurance card.
Complete all insurance information that applies.
Insured's Name * Insurance Company * Plan * Group Number ID/Member Number * Medical Information Does participant have any physical, emotional, or mental limitations, problems, or concerns that would be helpful if the staff was aware of or may affect the whole group, i.e. sleeping problems, destructive behavior? If yes, explain: Known Allergies Current Medication Name Dosage, Quantity and Frequency, Directions, Reason for Medication 2nd Medication Name Second Medication Dosage Third Medication Name Third Medication Dosage Fourth Medication Name Fourth Medication Dosage
I recognize that there may or may not be risks involved in participating in any activity. I hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in an activity at or through The Lutheran Church of the Holy Spirit.
To the fullest extent permitted by law, I release The Lutheran Church of the Holy Spirit, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless The Lutheran Church of the Holy Spirit, its trustees, officers, directors, employees, agents, representatives from any claims arising out of my minor child’s participation in an activity.
Further, being the parent or legal guardian of my minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child.
The taking of prescription medication is the responsibility of the individual taking the medication and/or that individual’s parent or guardian. A leader, after obtaining all the necessary information, may agree to accept responsibility to be sure a minor takes the necessary medication at the appropriate time, but LCHS does not mandate or encourage a leader to do so.
I have read and accept all of the provisions specified in this form.
Minor Child's Full Name * Minor Child Signature (6th grade and above) Date Single Line Text Single Line Text