My child, __________________________________________, has my permission to attend

I understand that the children will be traveling away from the church and that the Youth Staff and Leaders

will make every good faith effort and precaution to ensure my child’s safety. I release Immanuel Lutheran

Church and its Youth Staff and Youth Leaders from all liability should something happen to my child.

Parent Signature________________________________ Date_________________________

Printed Name __________________________________

Name_____________________________________________________________________________

Address ___________________________________________________________________________

City ______________________________________________ State_________ Zip _______________

Home Phone _______________________________________ Cell Phone _______________________

Social Security Number ______________________________

Any special medical needs _____________________________________________________________

___________________________________________________________________________________

Insurance Company Name _____________________________________________________________

Policy Number _____________________________________ Contact Person ____________________

In case of emergency please call ________________________ Relationship _____________________

Home Phone ____________________ Cell Phone __________________ Work Phone ______________

If I cannot be reached, please call ___________________________ at ___________________________

In the even I cannot be reached by phone and in an emergency, I hereby give permission to the physician

selected by the Immanuel representative to treat, hospitalize, order injection, anesthesia, or perform

emergency surgical procedures for my child named above.

Parent Signature________________________________ Date_________________________

Printed Name __________________________________

Notary ________________________________________ Seal