"Parents' Night Out" at CTL on Saturday, January 29th from 5:30-8pm  ~  Signup includes requesting Medical, Emergency, Hold Harmless Information
This form requests medical, release and liability information needed for the 1/29/22 event.

ONE FORM FOR EACH Participant, even if from same family (helps with headcount).  We will ask you to review and initial the information when you drop off the children.

Please note that you will have to complete the form and SUBMIT at the end before the information is actually sent to us.  If you close the form before submitting, you will have to start over.

Thank you! We are looking forward to a wonderful time!
Monies collected will go to the CTL Youth group activities fund.
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Child's First Name *
Child's Last Name *
Best Email Contact *
Child's Age *
First Emergency Contact *
Please type first and last name
Relationship of First Emergency Contact *
FIRST Emergency Contact's FIRST Phone Number to call *
Please include area code and hash marks:  ###-###-####
SECOND Emergency Contact *
Please type first and last name
Relationship of SECOND Emergency Contact *
SECOND Emergency Contact's FIRST Phone Number to call *
Please include area code and hash marks:  ###-###-####
Do you have another contact or other special contact instructions? *
If none, please type "none."
Does the participant have significant health concerns? *
Required
If Inhaler, EpiPen or Diabetic insulin is required, please enter location where it will be kept (Note: we may not have access to the Child Care or Classrooms) *
If none, please enter "none."
Other Notes: *
Required
Please add any other conditions/information about your child that you feel would be important for Volunteers to know *
If none, please enter "none."
If necessary, what is your first Hospital of Choice: *
list name and address (if not Waukesha Memorial)
Photography
I authorize and give consent to the CTL adults and volunteers and any of CTL's representatives to photograph my child and post the pictures on the bulletin board at church and in newsletters or other CTL media
Parent/Guardian Electronic Signature. *
I have read the above statement and indicate my agreement with my FIRST and LAST name.
Consent to Treat
I authorize and give consent to the CTL volunteers and any of CTL's representatives to seek and administer to myself, my child or any family member, any and all medical and hospital care, treatment and attention appropriate and necessary in the event of accident, injury, or sickness, until such time that I can be contacted.

I, the undersigned, understand that every effort will be made to contact me and the emergency contacts listed prior to initiating care, but treatment will not be withheld if contact cannot be made, as to insure the well being of my child.

I, the undersigned, certify that I am the parent or legal guardian of the participant. I also will be responsible for any and all costs associated with such necessary medical attention and/or treatment, including but not limited to transportation required for treatment.
Parent/Guardian Electronic Signature. *
I have read the above statement and indicate my agreement with my FIRST and LAST name.
Hold Harmless Release Waiver
By allowing my child to attend the Christ the Life (CTL) Parents' Night Out event, I acknowledge that there are inherent dangers and risks of injury and/or property damage to this activity, but I still desire my child to participate.

I agree to participate and allow my child to participate in the Parents' Night Out event which will be in, on or about the premises of Christ the Life Lutheran Church and Preschool and in any activity sponsored by or under the auspices of Christ the Life Lutheran Church and Preschool, and hereby release CTL Church and CTL Preschool, their officers, directors, employees, agents and representatives, from liability for any personal injuries and/or property damage resulting from any accident or any event arising out of the Parents' Night Out event that might occur to myself or to my child and family members while participating in CTL programs.

I do hereby indemnify and hold harmless the above mentioned organizations and/or individuals, their agents and/or employees, against any and all claims, actions, causes of actions, and any and all liability for personal injury, including injuries resulting in death to me, my child and/or other family members, or damage to my property, the property of my child and/or other family members, or both, while I or my child and/or family members participate in this CTL event.  

I, the undersigned, certify that I am the parent or legal guardian of the participant.  This authorization is valid for the CTL activity on Saturday, January 29th 2022.


Parent/Guardian Electronic Signature. *
I have read the above statement and indicate my agreement with my FIRST and LAST name.
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