24-25 Permission and Medical Release Form

24-25 Permission and Medical Release Form

Our Redeemer Lutheran Church - 825 Golf Ave. S.W. Pine City, MN 55063
Participant Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade
Parent/Guardian
Name

First NameLast Name
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Primary Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Alternate Emergency Contact

Please list someone other then the parent/guardian.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
grandmother, aunt, etc.
Medical Information
Insurance Company
Policy Number
Group Number
Insurance Phone Number
Known Allergies
Known Medical Conditions
Current Medications
Date of last Tetanus shot

MonthDayYear
Date
Any other limitations
In case of an emergency, I understand that every effort will be made to contact me. If I cannot be reached, I hereby give Our Redeemer Lutheran Church of Pine City, Minnesota permission to act on my behalf in seeking medical treatment for me/my child or ward in the event that such treatment is deemed necessary by Our Redeemer Lutheran Church staff.
I further blanks authorize/ blank do not authorize the youth director and/or other adult leaders to give my child, please check all medication below. :
Medication that can be given

TylenolIbuprofenPepto-BismolImodiumTumsExcedrinDramamine
And I hereby release and hold harmless Our Redeemer Lutheran Church, its staff, and volunteer adult chaperones, as well as staff and volunteers of all assisting groups and vendors, from any and all liability arising from my child's participation in these events. Effective October 1, 2024 - September 30, 2025.
Signature

Clear
Date

MonthDayYear
Date
This permission and medical release form will be kept on file for the calendar year of 2024-2025 as the dates listed above. Complete the form once and turn it in for the year. It is your responsibility to update any information as needed throughout the year. If you have any questions please feel free to contact Leigha Lange by phone at 629-2985 or by email at youthorlc@gmail.com
Should be Empty:

24-25 Permission and Medical Release Form

Participant Information

Parent/Guardian

Alternate Emergency Contact

Medical Information