Effective dates:  August 2007 through August 2008

Please print in ink 

Name: ___________________________________ Age ________ Birthday  __________
             Last              First              Middle

Year in school ______________  Male / Female      Email _________________________

Address ________________________ City _________________ State ___ Zip _______

Phone__________________________ Pager/cell ________________________

Medical insurance company ________________________Policy # __________________

Mother’s name _____________________Phone: (H)____________(Wk)______________

Father’s name _____________________ Phone: (H)____________(Wk)______________

Emergency contact ________________  Phone: (H)____________(Wk)______________

Physician __________________________Phone: ________________________________

Dentist ____________________________Phone:________________________________

MEDICAL HISTORY

Please describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach it to this form. Include names of medications and dosages that must be taken.

PLEASE ATTACH A COPY, FRONT & BACK, OF YOUR INSURANCE CARD.

Check the following areas of concern for this student. If necessary, add another page with details:

4. Date of last tetanus shot:  ________________________________________________

6. Please list and explain any major illnesses the child experienced during the last year:

 ___________________________________________________________________________________

  Additional comments:______________________________________________________

  Should this child’s activities be restricted for any reason?  Yes / No  Please explain:

 ___________________________________________________________________________________

For your information, we expect each student to conform to these rules of conduct

            No possession or use of alcohol, drugs, or tobacco
            No students can drive other students on an activity
            No fighting, weapons, fireworks, lighters, or explosives
            No offensive or immodest clothing
            No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters
            Participation with the group is expected
            Respect property
            Respect one another, staff, and adult leaders
            Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal limitations and code of conduct.

Student signature: ________________________________________  Date: ___________

Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, roller skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides and bowling.

                                                       has my permission to attend all youth activities
    Name of Student

sponsored by La Casa de Cristo Lutheran Church (hereinafter the “Church”) from  August 2007 through August 2008

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

Parent/guardian signature: ________________________________  Date: ____________