Lighthouse Medical Release Grades 6-12

Student Name *
Student Name
(required)
Address *
Address
(required)
Phone *
Phone
(required)
(required)
(required)
Person to Notify in Emergency *
Person to Notify in Emergency
(required)
Emergency Contact Phone *
Emergency Contact Phone
(required)
Emergency Contact Work Phone
Emergency Contact Work Phone
Contact Lenses *
(required)
I, who by law may do so, authorize the administration of emergency medical treatment to he/she who is subject of this form. I understand all reasonable safety precautions will be taken at all times by Christ’s Church or its agents. I will not hold Christ’s Church liable for any accident, injury or disease incurred to/by the subject of this form. I understand that in the event that medical intervention is needed, every attempt will be made to contact the person(s) listed above immediately. I will hold Christ’s Church or its agents harmless due to imprudent behavior from my teen. Furthermore, I will hold Christ’s Church harmless for any accident occurring by any means of transportation (e.g. plane, train, boat, automobile). This form will be effective for the duration of the time spent in the Christ’s Church youth program by the subject of this form. *
(required)
Parent/Guardian Name *
Parent/Guardian Name
By entering your full name, you are identifying yourself as the parent/guardian of the student named on this form: This is equivalent to your signature.