Zion Church of Millwood
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February 8, 2012


Lutherans Together in Spokane and the Spokane Valley

Safety Release Form
Anyone under the age of 18 must have this form filled out prior to the event they are participating in.
Events: Please list all events your youth will be participating in this month.
Name:
Email:
Address:
City:
State:
Zip:

Do you have any medical conditions?

 Are you currently taking medication?

 Do you have an allergies?
Comments:
If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your child is at the activity.

 Do you have health insurance?
Name of the Health provider
Policy
Group #
Whose name is the insurance under?
Family Doctor (please include address and phone number)
Family Dentist (please include address and phone number)
This form will be e-mailed directly to the Children and Family coordinator. By sending this form I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during youth activities, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. I understand all reasonable safety guidelines will be taken at all times by Zion Lutheran Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Zion Lutheran Church or the ELCA, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
  







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