Mount Calvary Lutheran | Holdrege, Nebraska

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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.

  • Emergency Contact (Not Parent/Guardian)

  • Child 1 - Registration & Medical Information

  • MM slash DD slash YYYY
  • Child 2 - Registration & Medical Information

  • MM slash DD slash YYYY
  • Child 3 - Registration & Medical Information

  • MM slash DD slash YYYY
  • Photo Release

  • 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.
  • MM slash DD slash YYYY

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Prayer Request

Prayer is talking to, asking, and honoring God. The Bible says that God listens to those who pray to Him and we would love to pray for you. Please call the church office at 308-995-2208 to request prayer.

News & Recent Updates

  • Holy Week Services
  • Moms In Prayer
  • Cookies for the Blood Drive
  • Child Care Ministry Informational Meeting
  • Lutheran Response Training

Services & Events

Location & Contact

Mount Calvary Lutheran Church
1419 East Avenue
Holdrege, Nebraska 68949
Phone: 3089952208

Our Mission

"Bringing the Good News of Jesus to all people for the first time and a lifetime."

Affiliation

Mount Calvary is a member congregation of The Lutheran Church Missouri Synod.

© Copyright 2016 Mt. Calvary Holdrege · All Rights Reserved