Medical Release

Please fill out this medical release form for all children PK – 12th Grade that will be attending Mt. Calvary’s Ministries. You can provide information for up to 3 children on this form. Please scroll all the way to the bottom to complete and submit.

Parent/Guardian 1
First Last
Parent/Guardian 2
First Last
Address
Street Address Address Line 2 City State ZIP Code
Cell Phone Number (Parent/Guardian 1)
Daytime Phone Number (Parent/Guardian 1)
Cell Phone Number (Parent/Guardian 2)
Daytime Phone Number (Parent/Guardian 2)
Parents' Email
Medical Insurance Company
Emergency Contact (Not Parent/Guardian)
Name of Emergency Contact (Not Parent/Guardian)
First Last
Home Phone Number (Emergency Contact)
Cell Phone Number (Emergency Contact)
Child 1 - Registration & Medical Information
Child's Name
First Last
Age
Birthday
MM slash DD slash YYYY
Year In School (2022/2023)
Student Cell Phone (optional)
Student Email (optional)
Gender
- Male
- Female
Physician's Name
Dentist's Name
Allergies
- Pollens
- Medications
- Food
- Insect Bites
- Other
Elaborate on Possible Allergies
Has this child suffered from, experienced, or is being treated for:
- Asthma
- Heart Trouble
- Frequently Upset Stomach
- Epilepsy/Seizure Disorder
- Diabetes
- Physical Handicap
Please Elaborate
Does this child wear
- Glasses
- Contact Lenses
Has the child had any major illnesses in the past year? If so, should the child's activities be restricted in any way?
Child 2 - Registration & Medical Information
Child's Name
First Last
Age
Birthday
MM slash DD slash YYYY
Year In School (2022/2023)
Student Cell Phone (optional)
Student Email (optional)
Gender
- Male
- Female
Physician's Name
Dentist's Name
Allergies
- Pollens
- Medications
- Food
- Insect Bites
- Other
Elaborate on Possible Allergies
Has this child suffered from, experienced, or is being treated for:
- Asthma
- Heart Trouble
- Frequently Upset Stomach
- Epilepsy/Seizure Disorder
- Diabetes
- Physical Handicap
Please Elaborate
Does this child wear
- Glasses
- Contact Lenses
Has the child had any major illnesses in the past year? If so, should the child's activities be restricted in any way?
Child 3 - Registration & Medical Information
Child's Name
First Last
Age
Birthday
MM slash DD slash YYYY
Year In School (2022/2023)
Student Cell Phone (optional)
Student Email (optional)
Gender
- Male
- Female
Physician's Name
Dentist's Name
Allergies
- Pollens
- Medications
- Food
- Insect Bites
- Other
Elaborate on Possible Allergies
Has this child suffered from, experienced, or is being treated for:
- Asthma
- Heart Trouble
- Frequently Upset Stomach
- Epilepsy/Seizure Disorder
- Diabetes
- Physical Handicap
Please Elaborate
Does this child wear
- Glasses
- Contact Lenses
Has the child had any major illnesses in the past year? If so, should the child's activities be restricted in any way?
Photo Release
I hereby grant Mt. Calvary Church permission to use photographs/videos taken of the minor(s) designated above in any manner or form for any purpose lawful at any time.
- Yes
- No
Medical Release
This child(ren) has my permission to attend and be transported to all Children’s Ministry/Youth Group activities sponsored by Mt. Calvary Lutheran Church, Holdrege, NE. This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of the named child(ren). I/We the undersigned have legal custody of the student named above, a minor(s), and have given our consent for him/her to attend events being organized by Mt. Calvary. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release Mt. Calvary, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Mt. Calvary, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Signing Parent/Guardian
First Last
Date
MM slash DD slash YYYY

Medical Release

Emergency Contact (Not Parent/Guardian)

Child 1 - Registration & Medical Information

Child 2 - Registration & Medical Information

Child 3 - Registration & Medical Information

Photo Release

Medical Release

Prayer Request

News & Recent Updates

Services & Events

Location & Contact

Our Mission

Affiliation