TIMOTHY LUTHERAN CHURCH- ST. LOUIS, MO MINOR/STUDENT PARTICIPANT PERMISSION / LIABILITY WAIVER- 2016 Participant Information Name: _________________________________________ Age: _______ Birthday: ___________ Address: ___________________________________ City: ____________________ Home phone #: __________________________

Cell#:________________________

State: ______

Gender: ____________ Zip: _____________

email: _______________________

Parent/Guardian Information Name: _______________________________________

Relationship to participant: _______________________

Address: ____________________________________ City: _____________________ State: ______ Zip:_____________ Home Phone#: ______________________ Business Phone#: ____________________ Email: _______________________ Parent One Cell Phone # : ______________________________

Parent Two Cell Phone # _________________________

Alternate Emergency Contact Information: Alternative Contact Name: ________________________________ Relationship to participant: ______________________ Home Phone#: ________________________________

Cell# ________________ Business #: _____________________

Address: __________________________________________________________ Email: ___________________________

Permission/Release of Liability - Parent of participant under the age of 18 By signing this waiver form, I give my permission for the child named above to participate in and engage in any Timothy Lutheran Church Youth Group events and /or activities scheduled from the signed date below through Dec. 31, 2016. These events /activities may occur either on or away from church property. My child is physically and mentally able to participate in these activities.. I acknowledge that there are certain risks involved in said events/activities, and expressly assume all risks of the child participating in the events/activities, whether such risks are known or unknown to me at this time. I release Timothy Lutheran Church, its pastors, youth leaders, paid staff, volunteers, and representatives of all responsibilities for any injuries, to body or property, which may occur to my child during the course of these events/activities, including transportation to or from events/activities. In the event of an emergency in which I, or the alternate contact name above, cannot be reached, I authorize the adult leaders to make medical decisions for my child, and to administer first aid if deemed necessary. I further agree to indemnify and hold harmless Timothy Lutheran Church and its pastors, youth leaders, paid staff, volunteers, and representatives of any and all claims arising from the participation of my child in Timothy Lutheran Church youth sponsored events/activities; or as a result of injury or illness of my child during such events/activities , including injuries/claims that may occur during transportation to or from said events/activities. I represent that I am the parent/guardian of ________________________________________, who is under 18 years of age. I have read the Permission/Waiver Form and I am fully aware of its contents. I give permission for the child named above to participate fully in the events/activities sponsored by Timothy Lutheran Church. _____________________________________________

_______________________

Signature of Parent/Guardian

Date

1 Timothy Lutheran Church-Jan.2016

MEDICAL WAIVER- 2016 Participant Name _____________________________ Age _________ Gender ________________ I, the undersigned, certify that I am the parent or legal guardian of _________________________ (hereafter the “minor child”). As the parent or legal guardian of the minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary by a physician, surgeon, dentist or other health care personnel for my minor child. I understand that all efforts will be made to contact me prior to treatment but, in the event I or my designated alternative emergency contact cannot be reached in an emergency, I give permission to Timothy Lutheran Church’s designated youth event/activity leader to make the decisions necessary for medical, surgical, or dental treatment. Should there be no activity leader available, I give permission to the attending physician, surgeon, or dentist to treat my minor child. As the parent or legal guardian, I understand that I have a duty to provide primary accident and medical insurance for my child and I declare that my child is covered by primary accident and medical insurance. I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child. Any insurance policy of Timothy Lutheran Church will be used only as the secondary coverage. It is understood that this authorization is given in advance of the occurrence of any condition or situation which would necessitate any such medical, surgical or dental care being required, but is given to provide authority to obtain such care if it should be required.

Signature of Parent/Legal Guardian

Primary Emergency Contact

Date

Name ________________________________________________________

Relationship to child _______________ Home phone _____________________ Cell Phone _________________ Alternate Emergency Contact

Name ________________________________________________________

Relationship to child _______________ Home phone _____________________ Cell Phone _________________ Medical Doctor Name ___________________________________ Phone _________________________ Dentist

Name ___________________________________ Phone _________________________

Health Insurance Information (please provide photocopy of insurance care front and back) Insurance Company _____________________________________ Phone # (_____)__________________ Insurance ID# _________________________________________ Group # _________________________ Dental Insurance ( if different) ______________________________ Phone # (_____)__________________ Health History Information Medication allergies (list) __________________________________________________ Food Allergies (list) ______________________________________________________ _____ Allergic to insects bites/bee stings

______ Heart disease/arrhythmias

______ Diabetes

_____ History of seizures

______ Physical disability

______ Asthma

If you checked any of the above, please give details (i.e., include normal treatment of allergic reactions): ___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Date of last Tetanus booster _____________ 2 Timothy Lutheran Church-Jan.2016