Medical Release Name First Middle Last AgeBirthday MM DD YYYY Year In SchoolGenderMaleFemaleAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parents' Email Is this email checked frequently? Yes Phone NumberCell NumberDoes this cell phone have texting? Yes Medical Insurance CompanyMother's Name First Last Home Phone (Mother)Work Phone (Mother)Father's Name First Last Home Phone (Father)Work Phone (Father)Name of Emergency Contact (Not Parent/Guardian) First Last Home Phone (Emergency Contact)Work Phone (Emergency Contact)Physician's Name First Last Dentist's Name First Last Allergies Pollens Medications Food Insect Bites Other Elaborate on Possible AllergiesHas this child suffered from, experienced, or is being treated for: Asthma Heart Trouble Frequently Upset Stomach Epilepsy/Seizure Disorder Diabetes Physical Handicap Please ElaborateDoes 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?I hereby grant Mt. Calvary Church permission to use photographs/videos taken of the minor designated above in any manner or form for any purpose lawful at any time.YesNoThis child 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. I/We the undersigned have legal custody of the student named above, a minor, 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 This iframe contains the logic required to handle AJAX powered Gravity Forms.