2016 - 2017 SCLCY Emergency Medical Information & Permission
This form is good for the 2016-2017 LCY Year. Fill it out once, we will keep this record for emergency use at events and save it for one year after.

Please contact Pastor Eric Wolf at eric@scsynod.com with any comments or questions.

Last Name
Your answer
First Name
Your answer
Primary Emergency Contact
Name of an Adult
Your answer
Date of Birth
MM
/
DD
/
YYYY
Primary Contact Phone Number
Your answer
Secondary Emergency Contact Phone Number
Your answer
Secondary Emergency Contact
Your answer
Medical Information
Allergies, special dietary restrictions, medications, and so on.
Your answer
Permission to Administer Over the Counter Medications
This is to help us understand what minor actions you'd like us to take if a situation doesn't warrant a call home or trip to the emergency room. Administration of any of these items is solely at the discretion of the adult designated for this task. We assume no liability for any side effects from medicines you authorize us to dispense. These are the ONLY medications we may choose to dispense.
Insurance Information — Name of Provider
Please provide the name of your insurance company in case of emergency.
Your answer
Insurance Information — Policy Number
Please provide your insurance policy number in case of emergency.
Your answer
Signature — Permission to Receive Emergency Medical Treatment
By selecting "Agree" and submitting this form, I hereby grant permission for the registrant to attend the 2016-17 LCY events. I further grant permission for him/her to receive emergency medical treatment as may be necessary for any injuries or illness that may occur during the event. I understand that every effort will be made to contact parents/guardians before any medical treatment is administered. I hereby release the SC Synod, ELCA, its agents and employees, from liability in connection with accident or injury, except as a result of gross negligence of the responsible party.
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