Messiah Lutheran Youth Ministries Emergency Information
Youth Name *
Your answer
Grade *
Birthdate *
MM
/
DD
/
YYYY
Parent Name(s) *
Your answer
Address *
Your answer
City *
Your answer
Zip *
Your answer
Phone *
Your answer
Email
(OPTIONAL)
Your answer
Medical Info *
Facts concerning the child/youth's medical history including allergies, medications being taken, and any physical impairments to which a physician should be alerted.
Your answer
Emergency Phone Numbers
Please fill in the numbers that are applicable.
Emergency Name 1
Your answer
Relationship 1
Your answer
Work Number 1
Your answer
Cell Phone Number 1
Your answer
Home Number 1
Your answer
Emergency Name 2
Your answer
Relationship 2
Your answer
Work Number 2
Your answer
Cell Phone Number 2
Your answer
Home Number 2
Your answer
Secondary Emergency Contacts
People to contact in the event of an emergency, if a guardian cannot be reached.
Neighbor/Relative 1
Your answer
Neighbor/Relative 1 Phone
Your answer
Neighbor/Relative 2
Your answer
Neighbor/Relative 2 Phone
Your answer
Neighbor/Relative 3
Your answer
Neighbor/Relative 3 Phone
Your answer
Important Info *
Please list any situations (personal, family, health, diet) that we should be aware of concerning your child/youth.
Your answer
Photo Authorization *
Permission to post pictures of youth in activities on Messiah's Facebook/website - no youth will be identified by name on social media.
First Aid Medications
The following list of over-the-counter medications is available in the Messiah Lutheran Church first aid kits. These are available to treat minor afflictions. The dosage is determined by the size/age of the child, and the specific direction listed on the medication. Please indicate whether or not these medications may be given to your child as needed. Reminder, you will be contacted immediately if illness develops, or emergency treatment is required.
Cortisone Cream *
Neosporin *
Anti-fungal Cream *
Liquid Bandage *
Sunscreen *
Advil *
Insect Repellant *
Solarcaine *
Caladryl *
Hydrogen Peroxide *
Pepto Bismol *
Anti-bacterial & alcohol wipes *
Cough Drops *
Tylenol *
Chloraseptic Lozenge *
Sudafed *
Benadryl *
Medical Treatment Authorization
Preferred Doctor's Name *
Your answer
Doctor Phone *
Your answer
Preferred Dentist's Name *
Your answer
Dentist Phone *
Your answer
Legal Guardian Authorization *
In the event reasonable attempts to contact the legal guardians from the above information have been unsuccessful, I hereby give my consent to take the above child/youth to a licensed physician or dentist or hospital and hereby give my consent and authorizations of any treatment deemed necessary by a licensed physician or dentist, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. (Please type your name to give consent.)
Your answer
Liability Release *
I understand all reasonable safety precautions will be taken at all times by Messiah Lutheran Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to not hold Messiah Lutheran Church, its leaders, employees, and volunteer staff liable for damages,losses, diseases, or injuries incurred by the child/youth of this form. (Please type your name to give consent.)
Your answer
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