Name of Child Participating:*

I give permission for my child to participate in all Church-related youth events with Christ Lutheran Church of Brenham, Texas.

I give permission for my child to participate in all Church-related youth events with Christ Lutheran Church of Brenham, Texas.*

Yes

I, the undersigned parent or legal guardian of a minor, do hereby authorize treatment of my child by licensed medical personnel in case of any accident, illness or hospitalization that may arise. If neither I nor the authorized persons listed on this permission form can be contacted in the event of an emergency, I give permission to Mrs. Sharon Schwartz, Rev. Mark Groves, and adult sponsors from Christ Lutheran Church to authorize, at my expense, such medical treatment as is recommended by the attending medical personnel. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Christ Lutheran Church through its accident policy will be used as backup for what my family's insurance does not cover. I understand that all reasonable safety precautions will be taken at all times by Christ Lutheran Church and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Christ Lutheran Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases or injuries incurred by the subject of this form.

This consent form will remain in effect until December 31, 2023.

Typing your name below is a binding signature

Name of Parent/Legal Guardian:*

Date:*

Contact Information

Telephone

Does your child have a parent or guardian?

My child has a mother and father.

My child has only one parent.

My child has a guardian

Mother's Personal Cell Number:*

Mother's Work Phone Number:

Father's Personal Cell Number:*

Father's Work Phone Number:

Guardian's Personal Cell Number:*

Guardian's Work Phone Number:

Parent's Personal Cell Number:*

Parent's Work Phone Number:

Emergency Contact

Contact 1

Name:*

First Last

Relation to Child:*

Phone Number:*

Contact 2

Name:*

First Last

Relation to Child:*

Phone Number:*

I wish to add a 3rd contact

I wish to add a third emergency contact

Contact 3

Name:

First Last

Relation to Child:

Phone Number:

Health and Insurance Information

Child's Date of Birth*

Does your child have any allergens?*

Yes.

No, my child does not have any major allergens.

List Each Allergen Here:*

Use the "+" on the right to add another row.

Does your child take any special medications?*

Yes

No

List Medications Here, or other information:*

Any other important health information?

Family Physician:

Phone:

Insurance Company:

Insurance Policy Number:

Insurance Phone Number:

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Parent Permission/Emergency Information Form

I give permission for my child to participate in all Church-related youth events with Christ Lutheran Church of Brenham, Texas.

This consent form will remain in effect until December 31, 2023.

Typing your name below is a binding signature

Contact Information

Telephone

Emergency Contact

Contact 1

Contact 2

Contact 3

Health and Insurance Information

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