Hope Lutheran Pioneer Registration Form Medical Information and Liability Release

Student's Name*

First NameLast Name

Date of Birth*

Date

MaleFemale

Current Grade*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Email*

Phone Number*

Please enter a valid phone number.

Parent/Guardian Name

First NameLast Name

Parent/ Guradian Email

Phone Number

Please enter a valid phone number.

Physician Name*

First NameLast Name

Physician Phone Number*

Please enter a valid phone number.

Dentist Name*

First NameLast Name

Dentist Phone Number*

Please enter a valid phone number.

Does your child have any condition or allergies we should be aware of?*

Name and dosage of any medications your child is taking:*

Health Insurance & Policy Number*

Please list anything that we should know about your child to help them have a good experience in Hope Lutheran Pioneers.*

The undersigned parent or legal guardian of the named student, a minor child in attendance at functions of Hope Evangelical Lutheran Church located in Irmo, South Carolina, does hereby grant permission for my child to particpate in all activities, trips, and programs in connection with Hope Evangelical Lutheran Church. I hereby acknowledge that my child is physically fit and capable of participating in all such activities. I further agree to admonish my child to exercise care, to be well behaved, and in all things obedient to and under the direction and control of those adults in authority. In the event I cannot be reached in an emergency, I hereby give my permission to the physican or dentist selected by Hope Lutheran Evangelical Lutheran Church to secure proper treatment, hospitalize, and/or order an injection, anesthetic, or surgery for my child as deemed necessary.

The undersigned parent or guardian will indemnify and hold harmless Hope Evangelical Lutheran Church and its officers, agents, servants, or employees from any and all claims or causes of action, and under no circumstances will the undersigned present any claims against Hope Lutheran Evangelical Church and said persons for personal injuries, property damage, wrongful death or otherwise, caused by Hope Lutheran Evangelical Church and said persons.

The undersigned (e-signed or ink signed) parent or guardian represents that he/she has read this Release, has requested and received, or has declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all liability associated with such dangers and risks, and is fully aware of and understands the terms and legal consequences of signing this Release. By checking the box below, I, the parent or guardian, agree to the terms listed in this Release.

I understand the cost of this program is $25 per child per year. Payment MUST be given to NICHOL HARE for accounting purposes. Checks may be made payable to Hope Lutheran Church.

Signature*