Microsoft word - activity release authorization.doc

Messiah Evangelical Lutheran Church
Participant Name ____________________________________________ Date of Birth _____/_____/______ Address __________________________________________________________________________________ City ____________________________________ State ________________ Home phone (_______)_____________________ Grade _______________ Parent/Guardian Name(s) _____________________________________________________________________ Home phone (_____)_________________ cell (_____)________________ work (_____)_________________ Emergency Contact (other than parent) ____________________________ Relationship __________________ Home phone (_______)_____________________ 2nd Phone (_______)_________________________ Medical Insurance Company__________________________________________________________________ Group/ Policy Number _______________________________________ Current medications _________________________________________________________________________ Please indicate below any medical needs the staff and/or adult leaders should be aware of:
Allergies (including insects, food and/or medication: Any illnesses (asthmas, bleeding, cold, flu): Any physical restrictions, medical problems or special needs: In the event of a medical emergency, I, the parent/guardian of the above named, do hereby authorize Messiah Lutheran of
Fargo, ND, to act on my behalf in seeking medical treatment for my child in the event that I or the emergency contacts
cannot be reached.
In consideration of the opportunity to participate in this church trip, and in recognition of the possible dangers voluntarily
subjected to; we hereby knowingly, freely and voluntarily waive and right or cause of action, of any kind, arising as a
result of such participation from which any liability which may or could accrue to Messiah Lutheran Church and the
individuals thereof.
I, the parent/guardian have also read and agree with the expectations listed below and will support Messiah Lutheran
Church in administering any appropriate consequences if expectations are not followed.
Parent/ guardian signature ______________________________________________
Date _________________

To ensure an outstanding Christian experience for everyone, students are expected to read and follow the expectations
listed here:
I will respect my body as a temple and refrain from use or possession of illegal drugs, alcohol and tobacco. Such actions will result in immediate dismissal from the event/trip at my parent’s expense, contact with local law enforcement and possible expulsion from future youth trips and events. The possession of weapons, firearms, fireworks or any other explosives is prohibited. I will respect assigned sleeping spaces as designated for males and females and lights out times. I will assume responsibility for all of my actions and will be held responsible for any resulting consequences. I will behave in a mature and responsible manner respecting group leaders, adults, peers and facilities. I will participate in all group activities with a positive attitude.
I, ____________________ (participant) have read the expectations and agree to abide by them. I understand that any
behavior that breaks an expectation will be dealt with immediately and may result in being sent home (transportation to be
determined) at my parent’s expense.
Youth Signature ______________________________________________________
Date _____________________
Messiah Evangelical Lutheran Churc *Please complete this section only as you feel necessary or for your youth or specific youth events. Over the Counter Medication
The following OTC medications may be available and provided by Messiah Lutheran Church. Please indicate below what OTC medications can be administered for the appropriate symptoms, according to the package directions. All medication(s) will be administered by adult leaders only! Acetaminophen (Generic Tylenol type for pain/fever) Ibuprofen (Generic Advil type for pain/fever) Meclizine (Generic Dramamine type for car sickness and dizziness) Prescription Medication Form
Prescription medications should be turned in to the trip/event leader as directed by the trip/event leader at time of registration and will be distributed by an adult as directions indicate. Exceptions are immediate response medications such as inhalers. Drug name ________________________________________________________________________________ Instructions for administering prescription: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Drug name ________________________________________________________________________________ Instructions for administering prescription: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Source: http://www.messiahfargo.com/Activity%20Release%20Authorization.pdf