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