Lakeside Minor Under 18 Consent & Release

CONSENT AND RELEASE FOR AN ADULT TO PARTICIPATE IN CHURCH EVENTS

This Document Contains IMPORTANT INFORMATION.Please READ IT CAREFULLY Before Agreeing To The Terms And Conditions!
Participants Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participants Phone
Format: (000) 000-0000.
For verification please upload a valid photo identification. (Drivers license, a state issued photo ID, or a Passport)

Cancelof
Email
example@example.com
Ministry and Event
Which Ministry Has Requested this Consent?
What is the Name of the EVENT that the participant will be attending?
Ex. Winter Retreat, Kids Camp, VBS, etc.
Emergency Contacts
Relationship to You
First & Last Name
Emergency Contact Phone
Format: (000) 000-0000.
Medical
Have you completed a 2024 Yearly Medical Authorization form?
Has anything changed or need to be updated on the 2024 Yearly Medical Authorization form?
For your convenience the Yearly Medical Authorization form will launch after you submit this form for you to complete and submit.
Please list any allergies, medications being taken, medical problems, etc.
CERTIFICATION, AGREEMENT & SIGNATURE

I understand that, in the event medical treatment is required and I am unable to make a sound decision every reasonable effort will be made to contact the emergency contact listed on this document. If the emergency contact cannot be reached, I give my permission to the staff or sponsor to secure the services of a licensed physician to provide the necessary care, including anesthesia, for my well-being.
Signature (Printed)
By my signature, I hereby acknowledge and agree to the terms and conditions contained herein.
Todays Date

MonthDayYear
Date
Should be Empty:

CONSENT AND RELEASE FOR AN ADULT TO PARTICIPATE IN CHURCH EVENTS

Ministry and Event

Emergency Contacts

Medical