Permission to Attend/Authorization for Medical Treatment

Lutheran Church of Dell Rapids

701 Orleans Ave, Dell Rapids, SD 57022 | 605-428-3197 |lcdr@siouxvalley.net
Permission to Attend/Authorization for Medical Treatment
Child's Full Name has my permission to participate in all activities of the Lutheran Church of Dell Rapids and to be transported by Church van or private car when necessary. I understand all events will have adult supervision. In consideration of the benefits to be derived from these activities, I hereby voluntarily waive any claim against the Lutheran Church of Dell Rapids, the sponsors, and the owner/or driver of the car or van furnishing transportation to any event. I further agree to direct my son/daughter to conform to the fullest with the directions and instructions of the sponsors in charge. This consent and release is in full effect until I give the Lutheran Church of Dell Rapids written notice to the contrary.
Parent(s)/Guardian(s):

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Email
example@example.com
Child's Birth Date

MonthDayYear
Date
Child's Current Grade in School
I give permission to post appropriate pictures of my child on the website or church related publications.

YesNo
Medical Care Permit
I hereby authorize emergency medical care of first-aid treatment as needed for (child's name)in the event of illness or injury during any sponsored activity of the Lutheran Church of Dell Rapids. This permit is in effect until I give the Lutheran Church of Dell Rapids written notice of the contrary.
Nearest Relative as Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Has he/she had any surgery or serious illness within the last 3 years?

YesNo
If yes, please explain:
Is he/she required to take any medications?

YesNo
If so, what medication and for what reason?
Does he/she have any allergies or allergic reaction to any medication or food?

YesNo
If yes, please explain:
Is he/she currently under a doctor's care?

YesNo
If yes, please explain:
Today's Date

MonthDayYear
Date
Parent/Guardian Signature

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Lutheran Church of Dell Rapids

Permission to Attend/Authorization for Medical Treatment

Medical Care Permit