Authorization for Treatment
This health history is correct as far as I know, and the person herein described has permission to engage in all youth activities except as noted.
I hereby give permission to the medical personnel selected by the youth director or adult leaders to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Redeemer Lutheran Church & Preschool to secure and administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named on page one of this document. I authorize the physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgment as to the requirements of such a diagnosis or medical, dental or surgical treatment.
I agree to remain fully liable and responsible for the payment of any such hospital, doctor, ambulance, dental or medical fees. I further agree that in giving this permission and authorization, Redeemer Lutheran Church & Preschool does not assume any responsibility or liability for the payment of such hospital, doctor, ambulance, dental or other medical fees which may be incurred. The completed forms may be photocopied and maintained by authorized personnel for transportation purposes.
Acknowledgement of Inherent Risk
I acknowledge and understand that there are inherent risks associated with many youth activities/trips. I will assume the risk associated therewith, whether known or unknown to me at this time. I recognize that my attendance at Redeemer Lutheran Church & Preschool activities and trips is a privilege and as consideration for this privilege, I release Lamb of God Lutheran Church, including its employees, pastors, agents, and volunteer youth workers, from responsibility from my accidental physical injury, including death or illness while at youth activities/trips. This release is also intended to include all claims made by my family, estate, heirs, personal representative or assigns.
If the student is under 18, my parent or guardian, by signing page one of this document, also agrees to all of the above and consents to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representatives and assigns. My parent or guardian also promises, by signing page one of this document to defend, indemnify and hold Redeemer Lutheran Church & Preschool harmless from any claim asserted by me against Redeemer Lutheran Church & Preschool, including its employees, pastors, agents, and volunteer youth workers, if I should repudiate this release after obtaining adulthood.
I/we also agree to bring my/our child home at my/our expense should they become ill or if deemed necessary by the student ministries staff member or volunteer youth workers.