Student Min Medical & Liability Release Form

Medical & Liability Release Form

St. John's Lutheran Church
Student Information
Student Name*

First NameLast Name
DOB*

MonthDayYear
Date
Age*
Grade*
School*
Student Cell Phone
Please enter a valid phone number.
I give permission for St. John's staff to text my student.

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Parent/Guardian (Primary Contact)*

First NameLast Name
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Secondary Contact*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email*
example@example.com
Student Medical Information
Student's Doctor*

First NameLast Name
Doctor's Phone Number*
Please enter a valid phone number.
Please list any allergies or dietary needs.*
N/A if this does not apply to your student.
Severity of Allergies*
*If you indicate that a life-threatening reaction is likely, we will call 911 if symptoms appear. EMT costs will be charged to you.
Other Conditions*
If above is other, please explain.*
N/A if this does not apply to your student.
If you checked any of the above, please give direction on steps that should be taken if symptoms appear:*
N/A if this does not apply to your student.
Name and Dosage of any medication (prescription or over the counter) that is to be taken: *
N/A if this does not apply to your student.
Any activity restrictions?*

YesNo
If yes, please explain.*
N/A if does not apply to your student.
Medical Release

Your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a St. John’s Lutheran church/school related activity.
Name of Health Insurance*
Policy Number*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I acknowledge that participation in St. John’s Lutheran church/school trips/activities involves risk to the Participant (and the participant’s parents or guardians, if participant is a minor), and may result in various types of injury including, but not limited to the following: sickness bodily injury, death, emotional injury, personal injury, property damage and financial damage.

In consideration for the opportunity to participate in St. John’s Lutheran church/school trips/activities, the participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of injury associate with participation in trips/activities. The participant (or parent/guardian) accepts personal financial responsibility for any injury sustained during the trip/activity. Further, the participant (or parent/guardian) promises to indemnify, defend, and hold harmless St. John’s Lutheran church/school and its agents, employees, volunteers, or any other representatives for any injury related directly or indirectly out of St. John’s Lutheran church/school trip/activity, whether such injury arises out of the negligence of St. John’s Lutheran church/school or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and St. John’s Lutheran church/school cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel or the American Arbitration Association for final resolution.
Parent/Guardian Signature*

Powered by Jotform SignClear
Today's Date*

MonthDayYear
Date
Photo/Video Use Waiver
I hereby grant, voluntarily and with full understand to St. John’s Lutheran church and school, a license of the following:
- Use and storage of my name and image, by means of digital or film photography, video photography, audio recording or other documentation, with respect to trips/activities, of St. John’s Lutheran church and school
- Use of any stored data including my name and image in printed publications, electronic publications, or any website created by St. John’s Lutheran for its sole benefit.
- If I am signing this agreement on behalf of a minor child, I hereby warrant that I am the legal parent or guardian of the child and that I have legal authority to sign this agreement on behalf of the child.
Video/Photo Us Waiver*

YesNo
Parent/Guardian Signature*

Powered by Jotform SignClear
Today's Date*

MonthDayYear
Date
Texting/Digital Communications Waiver
I hereby grant St. John’s Lutheran church and schools and my student permission to digitally communicate through means of email, text, social media, and any other forms of digital media. By signing this I understand that St. John’s has policies and procedures to promote safe and healthy digital communication that all youth workers, volunteers, and student participants must obey. Refer to our policies.
Texting/Digital Communications Waiver*

YesNo
Parent/Guardian Signature*

Powered by Jotform SignClear
Student Signature*

Powered by Jotform SignClear
Today's Date*

MonthDayYear
Date
Should be Empty:

Medical & Liability Release Form

Student Information

Emergency Contact

Student Medical Information

Medical Release

Photo/Video Use Waiver

Texting/Digital Communications Waiver