Consent, Liability, and Health Form
St. John's Lutheran Church
1403 Newman St., Bloomer, WI 54724
715-568-5446

This form serves the purpose of enabling children and youth to go on trips, service projects, and other events which occur at St. John's, offsite, or are fun by St. John's staff/volunteers. Signing this form allows your child to be involved in such events throughout the year. This form allows the responsible adult agent of St. John's to get medical attention to your child if it is deemed necessary and/or you cannot be contacted. Please read through thoroughly before signing.
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Child's/Participants Name and Date of Birth *
As parent/guardian of the above named minor, I do hereby authorize the treatment by a licensed medical physician or other appropriate health care provider for the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his /her life, cause disfigurement, physical impairment, or undue discomfort if delayed. The authority granted is only to be exercised after a reasonable effort has been made to reach me if time so permits. This release form is signed of my own free will and is for the sole purpose of authorizing necessary medical treatment or other health care under emergency circumstances in my absence. Please electronically sign and date. *
Parent/Guardian Name *
Address *
Phone (Primary) *
Phone (Secondary)
Family Physician Phone *
Family Dentist *
Specific medical allergies, chronic illnesses, disabilities, other pertinent medical information that applies to child participant listed *
Prescribed medicine your child is now taking *
Date of last tetanus immunization *
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Medical Insurance Company *
Policy Number *
Group Number *
Name of Policy Holder *
Alternate Emergency Contact Name, Phone, and Relation to Child *
To Whom It May Concern: As legal parent/guardian, I(we) hereby give permission for my child named above to attend and participate in activities sponsored by St. John’s Lutheran Church, Bloomer, Wisconsin. In the event that the parent cannot be reached in a timely manner,  I (we) authorize an adult agent of St John’s Lutheran Church to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnoses or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Action the medical staff of a licensed hospital, whether such diagnoses or treatment is rendered at the office of said physician or at said hospital.  The agent of St John’s Lutheran Church is allowed to share pertinent information about your child with appropriate medical personnel.  The undersigned shall be liable and agree(s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for my (our) child to return home prematurely for medical, legal, behavior, or other reasons, the undersigned shall assume all expenses involved. The undersigned also gives permission for my (our) child to be a passenger in any vehicle that has appropriate insurance coverage and is driven by appropriate person as designated by St. John’s Lutheran Church, Bloomer, Wisconsin. Please electronically sign and date. *
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