Beautiful SaviorLutheranChurch – 7706 S 96th St – LaVista, NE - 68128 – 402.331.7376

Medical Information, Consent, and Release of Liability Form

______(____)______

Last name of minor participant First name MI Home phone of guardian

____ Male______

____ FemaleDate of Birth Age Grade Social Security Number

______

Parent/Guardian Name Street address City State Zip

______(____)______(_____)______

Name – alternate adult contact Relationship to participant Phone – Day Evening

Emergency and Health informationPlease indicate anything you would want a medical professional to know regarding your child.

Does the following minor participant have… (if yes, please explain)

____yes ____noAllergies? ______

____yes ____noHeart condition? ______

____yes ____noother? ______

Is the following minor participant subject to…(if yes, please explain)

____yes ____noFainting? ______

____yes ____noSleep walking? ______

____yes ____noUpset stomach? ______

____yes ____noMotion sickness? ______

____yes ____noother? ______

Does the following minor participant have a negative reaction to…(if yes, please explain)

____yes ____noBee sting? ______

____yes ____noPenicillin? ______

____yes ____nootherdrugs? ______

____yes ____noPoison ivy, oak, sumac? ______

____yes ____noother? ______

Please indicate anything else leaders should know about to help in ensure that your minor participant has a positive experience.______

______

Date of last tetanus shot______

Insurance Co.______Policy #______

Name of policy holder______

Does your health insurance require pre-certification? ____yes ____no If yes, phone number (____) ______

Name of Doctor ______Phone (____) ______

The staff and youth leaders of BeautifulSaviorLutheranChurch have my permission to give my minor participant:

____yes ____noRobitussin (cough medication)____yes ____nomotion sickness medication(Dramamine etc.)

____yes ____noacetaminophen (Tylenol)____yes ____noantacid (Rolaids/Mylanta/Tums etc.)

____yes ____nodiphenhydramine (Benadryl)____yes ____noibuprofen (Advil etc.)

____yes ____notopical antibiotic ointment____yes ____notopical cortisone (Cortaid etc.)

____yes ____noPepto-Bismol, or Kaopectate____yes ____noskin ointment//treatment (SolarCaine, Chapstick, etc.)

____yes ____nocold medications (Dayquil, etc)____yes ____nogynecological medications (Midol etc.)

____yes ____no topical antiseptic (Betadine etc)____yes ____no Calamine/Caladryl

____yes ____no naproxen sodium (Aleve etc.)____yes ____no other (please specify)

Please list any medications your minor participant is taking on a regular basis or will be taking during this experience, including vitamins and/or nutrition supplements:______

Emergency Procedure: In the event of any emergency, the adult staff and youth leaders will attempt to first contact the parent/guardian of your minor participant.If this is not possible or if there is insufficient time to make such contact please note below:

With my signature below,

  • I authorize first aid administered by staff and adult leaders of BeautifulSaviorLutheranChurch.
  • I authorize emergency medical and dental care by hospital staff and or doctor selected byBeautifulSaviorLutheranChurchstaff or adult leaders and will pay all costs associated with such care.
  • I authorize the doctor selected by BeautifulSaviorLutheranChurchstaff or adult leadersto hospitalize, secure treatment for, and to order injection, anesthesia, blood transfusion or surgery. A plastic surgeon will be asked for any facial or neck injuries.
  • I authorize said minor participant to ride in vehicles designated by staff and adult leaders of BeautifulSaviorLutheranChurchwhile attending and participating in activities sponsored by BeautifulSaviorLutheranChurch
  • I authorize BeautifulSaviorLutheranChurchto use my minor participant’s voice and/or likeness in video, still photography, internet projects, or other means, in the various ministries ofBeautifulSaviorLutheranChurch.
  • I understand that if it should become necessary for my minor participant to return home due to medical, behavioral, or other reasons, I will assume all costs associated with transporting my minor participant.

I hereby consent to participation of my child (or myself) in the:

Elkhorn River Trip August 10-11, 2012

I understand that I have a duty to provide primary accident and medical insurance for my child (or myself) and I declare that my child is (or I am) covered by primary accident and medical insurance.

I release and forever discharge The Lutheran Church – Missouri Synod and Beautiful Savior Lutheran Church, Omaha Nebraska, their agents and servants, successors and assigns, directors, trustees, officers, employees, and other representatives from any and all damages and causes of action either at law or in equity that I may have as a result of my child’s (or my) participation in, attendance at, and travel to and from the trip.

Furthermore, I do hereby expressly stipulate, and agree to indemnify and hold forever harmless The Lutheran Church – Missouri Synod and Beautiful Savior Lutheran Church, Omaha Nebraska, its agents and servants, successors and assigns, directors, trustees, officers, employees, and other representatives against loss from any and all present or future claims, demands or actions in law or in equity that may hereafter be made or brought by me or my child, by anyone on behalf of my child or me, or by anyone else on their own behalf for damages or any other legal or equitable remedy on account of any injury, illness, physical condition, inconvenience or loss sustained by my child or me during the trip or travel to and from the same.

I, the undersigned, hereby acknowledge that I have read the foregoing, understand its contents, and have signed the same as my own free act and deed.

FOR PARTICPANTS AGE 21 AND OVER:

______

Participant SignatureDateWitness

FOR PARTICPANTS UNDER AGE 21:

______

Parent/Guardian signatureParent/Guardian signatureMinor participant signature