Youth Permission Form 2018-2019
St. Matthew's Lutheran Church -1700 Edmonds Ave. NE-Renton, WA 98056 425.226.2420
All youth participants must have this completed and on file to participate in off-site activities.
Student's Name (First, Last): *
Your answer
Date of Birth: *
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Age: *
Current Grade *
Parent(s)/Guardian(s): *
Your answer
Address:
Your answer
Best Phone: *
Your answer
Parent Cell Phone: *
Your answer
Student Cell Phone:
Your answer
Family Email: *
Your answer
Student Email:
Your answer
Student's Doctor: *
Your answer
Doctor's Phone: *
Your answer
Hospital Preference:
Your answer
State any medical issues including food allergies, physical, emotional, behavioral, or learning issues and/or special needs or concerns:
Your answer
Medication
If your student will be bringing medications during overnight events (prescribed or otherwise) please list below the type of medication, the dosage, and when it should be taken.
Medication/Dose/Time
Your answer
Emergency Contact Information
I give permission to any adult leader supervising my youth to secure any medical care they deem necessary while I, or my child, participate in any program sponsored by St. Matthew’s Lutheran Church. In a situation where medical care is required these steps may include, but are not limited to an attempt to contact a parent or guardian, administering basic first aid for minor incidences, seeking a professional medical examination and/or treatment, etc. Any expenses incurred for medical treatment will be the responsibility of the participant’s medical /dental coverage or family.
Parent/Guardian Signature *
Your answer
Date: *
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YYYY
Emergency Contact, if parents cannot be reached *
Your answer
Relationship to student:
Your answer
Emergency Contact Phone Number *
Your answer
Photo & Video Opportunities
I (We) grant to St. Matthew’s Lutheran Church the right to take photographs in connection with children/youth education classes, summer programs, and any other Church sponsored event. I (We) authorize St. Matthew’s Lutheran Church its assigns and transferees to copyright, use, and publish the same in print and/or electronically. I (We) agree that St. Matthew’s Lutheran Church may use such photographs for any lawful purpose, as indicated below.
Check all that apply:
I(we) have read and understand the statement above (parent signature): *
Your answer
Parent/Guardian Signature
I have read the information on this form and filled in the requested information to the best of my knowledge. I understand that it is my responsibility to inform St. Matthew’s if this information changes in the future. I hereby release St. Matthew’s from any liability as a result of my or my child’s participation in programs sponsored by St. Matthew’s Lutheran Church.
Parent/Guardian Signature *
Your answer
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