KINGDOM KIDS CHILDREN'S MINISTRY HEALTH FORM

KINGDOM KIDS HEALTH FORM
822 Belvoir Avenue - Chattanooga, TN 37421
DCE/Youth Director Contact: dce@gslcflock.org
Kingdom Kids Health Form

For K5 - 4th Graders (Kingdom Kids Children's Ministry)
Valid from August 1, 2026 through July 31, 2027

(NOTE: Our health forms are good for one year, and we renew all of the forms at the beginning of each school year. If you have already turned in one health form for the ^above-stated time frame, you do not need to submit another until the next renewal period - unless your information has changed.)

This form constitutes a permission statement for all of the Kingdom Kids Children's Minsitry events with Good Shepherd Lutheran Church, First Lutheran Church, and Cross of Christ Lutheran Church, which must be fully completed and signed by the child's parent or guardian.
Basic Student Information
Student's Full Name

First NameLast Name
Sex
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Grade
Home Address
City State Zip
Child Resides with:

Parent & Emergency Contact Information
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Alternate Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Primary Contact Email
example@example.com
Parent/Guardian Alternate Email
example@example.com
Person to be contacted if/when parents cannot be reached (Alternate Contact):

First NameLast Name
Phone Number of Alternate Contact^
Please enter a valid phone number.Format: (000) 000-0000.
Address of Alternate Contact^
Person who will assume responsibility for all medical expenses:

First NameLast Name
Contact Information for the person who will assume responsibility for all medical expenses (*if they are persons other than this child's parents/legal guardian):

General Health/Allergy & Safety Information
1) Does your child have any allergies or food sensitivities? If so, please list them below and describe the severity of their allergic reactions when exposed to different levels of those allergens.
2) Does your child take any prescription medication regularly? If so, please list it below and let us know if this medication needs to be with them at all times (i.e. - an inhaler, epipen, insulin, allergy meds, topical solutions, etc...).
If you give us permission to also distribute other basic medications to your child in appropriate doses such as children's Ibuprofen/Tylenol/Tums/etc... please initial here:
Initial
3) Are there any activities that your child cannot or should not participate in due to health, injury, or other concerns? If so please list those activities below:
4) Any other concerns or health information we need to know? Please note below:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ParentGuardian Signature

Health Insurance Information
Insurance Company Name
Insurance Company Address
City State Zip
Insured Person
Insurance/Certificate Number
Group Number
Please upload a photo of your insurance card (front and back) here:

Cancelof
AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR
We, the undersigned parents/guardian of the aforementioned minor child, do hereby authorize the Pastor and/or the Director of Youth Ministries and their designee(s) of Good Shepherd Lutheran Church, First Lutheran Church, and Cross of Christ Lutheran Church in Chattanooga, Tennessee, to act as agents of the undersigned to consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment, including first-aid and hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Tennessee Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician at a hospital or any location supervised by Good Shepherd's/First's/Cross of Christ's personnel. This authorization also applies to dental care under a dentist licensed under the Dental Practice Act as well as to providing first-aid on the campuses of Good Shepherd Lutheran Church, First Lutheran, and/or Cross of Christ - as well as on any field trips, or in connection with any other activities sponsored by any or all of the three aforementioned churches.

It is understood that this authorization is given in advance of any specific diagnosis, treatment (including first-aid) or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all diagnosis, treatment (including first-aid) or hospital care which the aforementioned physician in the exercise of his/her best judgment may deem advisable; and neither said agent(s) or any organization involved, including without limitation Good Shepherd Lutheran Church, First Lutheran Church, and Cross of Christ Lutheran and/or any of their designees, assumes liability or financial responsibility for exercising the power given by this authorization. This authorization is given pursuant to the provisions of the Family Code of Tennessee and shall remain effective until revoked in writing and delivered to said agent(s).
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signed: Signature of parent(s) or person having legal custody or the legal guardian of the student named above
Signed

Requirements & Info for Drop-off/Pick-up
Please understand that you will be required to drop off everything your child needs (diaper bag, allergy-specific snacks if needed, changes of clothes, sunscreen, medicine, etc...) when you bring them to the nursery and/or any of our other children's ministry programs or events (including VBS, Sunday School, etc...)

*Please initial here:
Initial
Who else (if anyone) other than yourself, your spouse, other immediate family members, or our current nursery children's ministry workers is allowed to pick up, drop off, or chaperone/accompany your child? (i.e. - family friends, other church members, teenage friends of driving age, neighbors, etc...)
^Please list their full names AND their relationships to you/your child below. They will need to present ID upon arrival to pick up your child. This is an extra safety measure.
NOTIFICATION OF PUBLISHING OR SHOWING MINOR CHILD'S STILL OR MOVING IMAGE
I, the parent/guardian of the aforementioned minor child, understand that pictures may be taken during the activities at Good Shepherd Lutheran Church, First Lutheran Church, and/or Cross of Christ Lutheran Church of Chattanooga, TN, or under their direction, then presented in various church-sponsored media. These include, but are not limited to, pictures, video productions, newsletters, television programs, web casts, brochures, handbooks, programs, social media posts, and Internet web pages. This section serves as notification to you that any meetings, events, and activities (including worship) are considered public and may be video-taped and/or photographed and used in the above listed manner.
Signature

Connect With Us & Stay in the Loop

Consent to Contact
How can we stay in touch with you?
Consent to Contact (if given above) - Please initial here
HOME CHURCH INFO (for visitors/non-GSLC members only):
Do you have a home church already?
If so, which church do you attend?
How long have you been attending there?
*If you do not yet have a home church, we would love for you to join us!

Please check out our websites: gslcflock.org | first4u.org | cocluth.com
for Service Information, Bible Studies, Small Groups, and Event Schedules. And, please don't hesitate to reach out to our offices if you have any questions (office@gslcflock.org | secretary@cocluth.com | office@first4u.org). We hope to see you at church soon!
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ParentGuardian Signature
Should be Empty:

KINGDOM KIDS HEALTH FORM

Kingdom Kids Health Form

Basic Student Information

Parent & Emergency Contact Information

General Health/Allergy & Safety Information

Health Insurance Information

AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR

Requirements & Info for Drop-off/Pick-up

NOTIFICATION OF PUBLISHING OR SHOWING MINOR CHILD'S STILL OR MOVING IMAGE

Connect With Us & Stay in the Loop