24-25 Lakewood Kids Medical

Lakewood Kids

Medical and Liability Release Form
The parent(s)/legal guardian(s) recognizes that Child's Full Name with a birthdate of Birthdate may participate in any and all Lakewood Christian Church (Lakewood Kids) sponsored activities during the entire 2024-2025 calendar year.
Grade in School*
Parent(s) Legal Guardian(s) Name(s)*

First NameLast Name
First NameLast Name
Main Contact Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Alternate Contact in the Event of an Emergency
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Child*
Child's Physician*
Physician Phone Number*
Please enter a valid phone number.
Please check non-prescription medications you could allow to be administered to your child in the even of injury or illness at a Lakewood Kids event.

IbuprofenTylenolCough DropsAntacidsSunscreen/Aloe
Insurance Information
Insurance Company*
Policy Number*
Group Number*
Please list any pertinent health information pertaining to your child. (i.e. restrictions, severe allergies, prescription medications, etc.)
Release:

Transport: I understand that my child may be transported in various vehicles/buses/cars as a part of group activities and trips, and I give standing permission for this transport.

Publicity: I understand that my child's image will be captured by photos/video/similar during events. I give permission for images/recordings of and writing by my child to be used in newsletters, emails, websites, pamphlets, social media, and similar forms of communication/publicity.

Activities: The parent(s)/legal guardian(s) recognizes and affirms that youth activities may be hazardous and include but are not limited to: hayrides, horseback riding, swimming, amusement parks, and any other activity in which the church youth may engage. The parent(s)/legal guardian(s) recognizes that their youth participate in such activities at their own risk, that they voluntarily assume those risks, and that they are fully familiar with all of the inherent dangers. This release is executed between Lakewood Christian Church and the parent(s)/legal guardian(s) of the youth whose name is listed above. Such release applies for any and all loss or damage and any claim or damage resulting from any church-sponsored activity in which your child is involved.

Liability: I hereby release Lakewood Christian Church, its personnel, volunteers, employees, officers, directors, and agents from any and all claims, liability, responsibility, and actions of every kind, including, but not limited to property damage, personal injury, or public liability which they may have or which may result from the participation of my child in various activities.

Medical: By signing this form, the parent(s)/legal guardian(s) also releases all youth leaders, pastors, and/or any member of Lakewood Christian Church from any and all liability, including but not limited to, on account of first aid treatment or service rendered to their child during participation in any church activity. In case of emergency, every effort will be made to contact parents. The signature on this release form hereby grants permission for my child to receive all necessary medical treatment (unless written otherwise on this form). The parent(s)/legal guardian(s) further states that he/she has carefully read this release and knows the contents thereof, and sign this release of their own free act.
Signature*

Clear
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Lakewood Kids

Alternate Contact in the Event of an Emergency

Insurance Information