Author: Admin

Student Medical Release and Parental
Permission Form
Lutheran Church of Our Saviour
8831 Fairmount Dr. S.E.
Calgary, AB

Student Name: _________________________________________________________________________
Birthday: _______________________________________ Sex: ____________ Age: __________________
School: ________________________________________________________ Grade: _________________
Student Email: _________________________________________________________________________
Student Cell Phone: ___________________________Student Home Phone: ________________________
Student’s AB Health Care Number: __________________________________________________________
Name of Family Physician: _______________________________________ Phone: ___________________
Current Medications: _____________________________________________________________________
Allergies (food, drugs, etc.): ________________________________________________________________
Anything else we should know: _____________________________________________________________
_______________________________________________________________________________________

First Parent or Guardian Name: ________________________________________________
Home Address: _____________________________________________________________
Number and Street City Postal Code
Parent Email: __________________________________Parent Home Phone ________________________
Parent Business Phone: __________________________ Parent Cell ______________________________
Second Parent or Guardian Name: _________________________________________________________
Home Address: __________________________________________________________________________
Number and Street City Postal Code
Parent Email: __________________________________Parent Home Phone _________________________
Parent Business Phone: _________________________ Parent Cell: ________________________________
In Case of Emergency please contact: _______________________________________________________
Home Phone: ___________________ Cell Phone: _______________ Relationship: __________________

Consent Form (Read carefully before signing – both student and parent/guardian)
I verify that all statements on this form are true and correct and that I have legal custody and guardianship of the Student.
The Student has permission to attend any activities sponsored and/or endorsed by the Lutheran Church of Our Saviour, Calgary, AB. Activities may include but are not limited to the following: day and overnight trips (chaperoned), recreation events, camps, weekly bible studies, small groups, service projects, fundraisers, etc. I hereby give permission for my student to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in events sponsored by Lutheran Church of Our Saviour. I also give permission for my student to be photographed and those photos to be used for publicity purposes.
I take responsibility and am liable for the Student’s actions, including but not limited to any damage that Student causes to property, while on the trip.
Authorization for Treatment: I hereby give permission to medical personnel to administer treatment, including hospitalization, to the Student in event of an emergency.
Release Form (Read carefully before signing – both student and parent/guardian)
The Student and parent/guardian:
In consideration of the privilege of attending events , I hereby release Lutheran Church of Our Saviour, including any of its directors, officers, trustees, employees, volunteers, leaders and agents, for all liability of any kind for the Student’s physical injury, including death or illness, while attending any events in the September 2014-August 2015 year. I will assume all risks associated with the activities, whether known or unknown to me at this time. This release is also intended to include all claims of the Student’s family members, estate, heirs, personal representatives or assigns.
Parent/Guardian:
I agree to defend, indemnify and hold Lutheran Church of Our Saviour harmless from any claim asserted by the Student against Lutheran Church of Our Saviour, including its directors, officers, trustees, employees, volunteers, leaders and agents, if the Student should repudiate this Release after obtaining adulthood.
I have read and understand this Release prior to signing it and I am aware that by signing this Release I am waiving certain legal rights that the Student may have against Lutheran Church of Our Saviour
Date:______________ Student Signature: ___________________________
Parent/Guardian Signature: _______________________________________
Signature of Witness: ___________________________________________
Name of Witness: ______________________________________________

First Parent or Guardian Name: _________________________________
Home Address: ______________________________________________
Number and Street
___________________________________________________________City Province Postal Code
Parent Email: ________________________________________________
Parent Cell Phone: ____________________________________________
Parent Home Phone: __________________________________________
Parent Business Phone:________________________________________