Confirmation 2018-2019 Parental Permission and Medical Treatment Consent Form
Please fill out this form to be kept on file for the 2018-2019 school year. This will apply to any field trips or service projects that the confirmation program does off site.
Student Name *
Your answer
Student Birth Date *
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DD
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Student Home Address *
Your answer
Student Email
Your answer
Parent/Guardian Name(s) *
Your answer
Parent/Guardian Phone *
Your answer
Parent/Guardian Alternate Phone
Your answer
Parent/Guardian Email *
Your answer
Emergency Contact (if parent/guardian is unavailable) *
Your answer
Emergency Contact Phone *
Your answer
Insurance Company *
Your answer
Insurance Company Address
Your answer
Insurance Policy #
Your answer
Insurance Primary Policy holder *
Your answer
Any medical conditions or allergies to be aware of *
Your answer
Current Medications
Your answer
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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