SSM WAIVER AND HEALTH FORM

SALEM STUDENT MINISTRY WAIVER

Valid September 1, 2026 through August 31, 2027.
YOUR EMAIL (person completing form)
example@example.com
STUDENT(S) INFORMATION
Student's Full Name

First NameLast Name
Sex
Date of Birth

MonthDayYear
Date
- Additional Student's Name
  
  First NameLast Name
- Sex
- Date of Birth
  
  MonthDayYear
  Date
- Additional Student's Name
  
  First NameLast Name
- Sex
- Date of Birth
  
  MonthDayYear
  Date
- Student Resides with:
- Father Full Name
  
  First NameLast Name
- Father Cell
  Please enter a valid phone number.Format: (000) 000-0000.
- Mother Full Name
  
  First NameLast Name
- Mother Cell
  Please enter a valid phone number.Format: (000) 000-0000.
- Contact Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Contact Number When Parents Cannot Be Reached
  Name, Relationship, and Phone Number
- MEDICAL INFORMATION
- IMPORTANT ALLERGIES OR MEDICATIONS (LIST HERE WITH NAMES)
  Type NONE if there are none.
- INSURANCE INFORMATION
- Insured Person Name* Insurance Carrier* Group/Policy Number* Hospital/Doctor Contact Number
- AUTHORIZATION AND CONSENT TO TREATMENT OF MINOR
  
  (We), the undersigned parent(s)/guardian of this above named minor, do hereby authorize the Pastor, the Director of Youth Ministries, and any designee of Salem Lutheran Church, Orange, California, as agent 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 California Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician, at a hospital, or any location supervised by Salem’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 Salem Lutheran Church’s campus, field trips, or in connection with any other Salem Lutheran Church sponsored activity.
  
  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 Salem Lutheran Church, assumes liability or financial responsibility for exercising the power given by this authorization. This authorization is given pursuant to the provisions of Sections 6901, 6902, 6903, and 6910 of the Family Code of California and shall remain effective until revoked in writing and delivered to said agent(s).
- Signature
  
  Please Sign Here
- AUTHORIZATION AND NOTIFICATION OF CAPTURING AND/OR PUBLISHING MINOR'S STILL AND/OR MOVING IMAGE
  
  I, the parent/guardian of the above named minor, understand that pictures may be taken during the activities at Salem Lutheran Church of Orange, CA, or under its direction, then presented in various church-sponsored media. These include, but are not limited to, pictures, video productions, newsletters, television programs, webcasts, brochures, handbooks, programs, 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
  
  Please Sign Here
- The undersigned parent or guardian of the above-named minor(s) by this agreement, agrees to exempt and relieve Salem Lutheran Church and any and all servants or employees thereof from liability for personal injury, property damage, or wrongful death of the above-named minor(s), caused by any act of negligence of Salem Lutheran Church and its agents, servants, or employees. If any portion of this release is held invalid, the balance shall continue in full legal force and effect.
  
  The undersigned parent or guardian of the above-named minor(s) for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against Salem Lutheran Church or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless Salem Lutheran Church and its officers, agents, servants, or employees from any and all claims or causes of action by the above named minor, or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of the above named minor present any claim against Salem Lutheran Church and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by Salem Lutheran Church and said persons.
  
  The undersigned parent or guardian acknowledges that he/she has read this Release, and has requested advisement on the potential dangers and risks of engaging in or observing the activities or instruction offered, assumes all risks associated with such activities' dangers and risks, and fully understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
- Signature
  
  Please Sign Here
Should be Empty:

SALEM STUDENT MINISTRY WAIVER

STUDENT(S) INFORMATION

MEDICAL INFORMATION

INSURANCE INFORMATION