Lakewood Edge & Lifeteen 2022 Participant Release
Thank you for filling out our yearly release form. It is a bit long, but filling this out once per year allows us to keep our various event registration forms much simpler, and saves you from having to repeatedly fill out the same information.

Please feel free to contact me with any questions regarding our youth programming.

Joe Costello
St. Luke's Youth Minister
jcostello@stlukelakewood.org
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Participant's Name *
Participant's Grade *
Participant's Birthdate *
Participants Phone Number / Please mark Home or Cell *
Name of Parent / Guardian #1 *
Parent / Guardian #1 Phone Number *
Name of Parent / Guardian #2
Parent / Guardian #2 Phone Number
Additional Emergency Contact Name #1 *
Emergency Contact #1 Phone Number *
Emergency Contact #1 Relation to Participant *
Additional Emergency Contact #2 Name *
Emergency Contact #2 Phone Number
Emergency Contact #2 Relation to Participant
Primary Care Physician Name *
Primary Care Physician Phone Number *
Preferred hospital for treatment
Health Insurance Carrier *
Name of Policyholder *
Member Number *
Group Number *
Medical Diagnoses
Current Medications
Medication Allergies
Food Allergies / Requirements
Other Important Info
For Headache you may give me child (select all that apply)
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For Upset Stomach you may give me child (select all that apply)
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For Allergies you may give me child (select all that apply)
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Medication Release

I give my permission for the over the counter medications, which I have selected herein, to be given to my child. I acknowledge the doses will align with the recommendations provided by the manufacturer.

I recognize that I may refuse to provide a signature if I do not consent to my child being given medication.

By typing my full name below, which shall constitute my electronic signature, I further acknowledge that I am the parent or legal guardian of the Child(ren) named in this release and have the authority to sign this document and act on his/her behalf.  I agree that my electronic signature is intended to authenticate this writing and to have the same force and effect as my manual signature. 

TYPE FULL NAME

Medical Release

As a condition of attending all St. Luke’s youth ministry sponsored activities in the year 2022, including but not limited to: weekly meetings, retreats, conferences, social gatherings, off campus field trips, volunteer opportunities, and all other events not named herein, but sponsored by St Luke’s Youth Ministry, this form must be completed.

In the event of an emergency or accident I grant permission for emergency medical care to be administered to my child.

I hereby authorize St. Luke’s staff and/or volunteers to provide for, seek, and authorize:  (1)The administration of any treatment deemed necessary by my child's primary care physician, listed above. In the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of my child to the preferred hospital I have designated above, or any hospital reasonably accessible.

I understand this authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained before surgery is performed.

I understand that it is my responsibility to carry appropriate medical insurance for my child/myself and that such is not the responsibility of any other person or party, including, without limitations, St. Luke the Evangelist Church and its staff and volunteers, St. James Church, St. Clements Church, the Diocese of Cleveland, and the bishop of the Diocese of Cleveland. My signature of consent attests that any and all information concerning my child’s medical history, including allergies, medications, and physical impairments, has been reported accurately on this form. 

By typing my full name below, which shall constitute my electronic signature, I further acknowledge that I am the parent or legal guardian of the Child(ren) named in this release and have the authority to sign this document and act on his/her behalf.  I agree that my electronic signature is intended to authenticate this writing and to have the same force and effect as my manual signature. 

TYPE FULL NAME
*
Photo Release

I grant permission to St. Luke the Evangelist Parish and its authorized representatives to record pictures and/or videos of my child’s participation in parish and youth ministry sponsored events. I further agree that any or all of the material recorded may be used, in any form, as part of any future physical or electronic publications used to promote St. Luke the Evangelist Parish, St. Clement Parish, St. James Parish, Lakewood Lifeteen & Edge, and the diocese of Cleveland.

I understand I may refuse to provide my signature. I understand that by refusing to consent my child's image will not be used, my child may be asked to step out of group photos, or my child's image will be removed or blurred from photos which will be published in any format.

By typing my full name below, which shall constitute my electronic signature, I further acknowledge that I am the parent or legal guardian of the Child(ren) named in this release and have the authority to sign this document and act on his/her behalf.  I agree that my electronic signature is intended to authenticate this writing and to have the same force and effect as my manual signature. 

TYPE FULL NAME

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