Parental Permission and Medical Treatment Consent Form
Student Name *
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Student Birth Date *
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Student Home Address *
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Student Email *
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Parent/Guardian Name(s) *
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Parent/Guardian Home Phone(s)
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Parent/Guardian Mobile Phone(s)
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Parent/Guardian Email(s)
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Name of Emergency Contact (if parent(s)/guardian(s) unavailable) *
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Emergency Contact daytime phone number *
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Insurance Company *
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Insurance Company Address
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Insurance Policy #
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Insurance Policyholder *
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Any medical conditions/allergies?
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Current medications:
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Date of last tetanus booster *
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Participation Consent: I hereby authorize my child to participate in St. John’s Lutheran Church sponsored events. I understand there are inherent risks involved in these activities and release St. John’s Lutheran Church 301 8th Ave Kasson, MN 55944 and any appointed chaperone of any liability pertaining to an injury sustained during the course of an activity. In the event of an accident, every effort will be made to contact a parent or guardian; however, if the delay of medical treatment would be detrimental to the health of the student, authorization for consultation and treatment by a physician is requested. All medical expenses incurred are the responsibility of the parent/guardian. *
Medical Consent: I understand that there is not medical insurance coverage provided by St. John’s Lutheran Church and hereby release St. John’s Lutheran Church and any appointed chaperone for any incidents that may occur while participating in St. John’s events. I agree to the above terms and give permission to any duly licensed dentist, physician or surgeon to perform emergency service for my child. *
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