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)
Photo Release: *
I hereby authorize Christ's Church Federal Way, hereafter referred to as “Company,” to publish photographs taken of myself and/or the minor child listed on this form, and our names and likenesses, for use in the Christ's Church's print, online, social media and video-based marketing materials, as well as other Company publications.   I hereby release and hold harmless Christ's Church from any reasonable expectation of privacy or confidentiality for myself and for the minor child listed on this form associated with the images specified above. Further, I attest that I am the parent or legal guardian of the child listed and that I have full authority to consent and authorize Christ's Church to use their likenesses and names.   I further acknowledge that participation is voluntary and that neither I, the minor child, will receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.    I hereby release Christ's Church, its contractors, its employees and any third parties involved in the creation or publication of Company publications, from liability for any claims by me or any third party in connection with my participation or the participation of the minor children listed on this form.
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.