Child's Name *
Child's Name
Address
Address
Parent 1
Parent 1
Cell Phone # *
Cell Phone #
Parent 2
Parent 2
Cell Phone #
Cell Phone #
Phone *
Phone
Insurance Provider - Policy Number
Doctor Name and phone Number
In addition to the named parents, please list persons to whom your child(ren) may be dismissed.
I hereby give my child permission to participate in the Youth and Family Ministries at David Evangelical Lutheran Church. I/We understand the risks inherent in such an activity and am/are willing to assume those risks, and release David Evangelical Lutheran Church -their staff, members, and volunteers from liability for any injury to the person and/or property of my child arising out of his/her participation in an activity. I understand all reasonable safety precautions will be taken at all times by David Evangelical Lutheran Church (Canal Winchester, OH) and its agents during events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I will not hold David Lutheran Evangelical Church (Canal Winchester, OH), it's leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the child/youth of this form. *
I have read and agree to the Permission and Release Information