First Lutheran Church Youth Permission Slip
Medical information and transportation permission for youth trips and activities for First Lutheran Church in Sauk Centre, MN
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Event Student Will Be Attending *
Student Name *
Parent Name *
Email Address  *
Phone Number *
Address  *
Name and Phone Number of Primary Physician  *
Emergency Contact #1 (Name, Phone, Relationship) *
Emergency Contact #2  (Name, Phone, Relationship) *
List any allergies to medication, food, seasonal, etc. (leave blank if none)
List of any current medications being taken (leave blank if none)
Any medical or health conditions we should be aware of?
MEDICAL PERMISSION:

Medical-Surgical Release: I understand that every effort will be made to contact me if my child needs emergency medical-surgical treatment. If it is impractical or impossible to make such contact, I give permission to the church adult counselors to give permission to a physician or nurse to secure proper treatment, to hospitalize, to order injections, anesthesia or surgery for the above named minor.
 *
Required
TRANSPORTATION AGREEMENT: 

I hereby give permission to First Lutheran Church, to transport my child to and from events.

I understand that by allowing First Lutheran Church to transport my child to and from this event, I am agreeing to release First Lutheran Church, it’s employees, and it’s volunteers from any liabilities, losses, damages, claims or actions to the maximum extent permissible by law, that may arising out of such transportation.
Electronic Signature (Type Full Name) 
Date
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