2024 Sunday School Registration, Medical Release, and Waiver Form

Registration

Full Name of Minor

Birthday

Address

Full Name of Parent/Guardian

This address will receive a confirmation email

Home/Cell Phone

Work/Other Phone

I give permission for the Sunday School teacher to sign my child in and out of class during the church service.

Yes No

Medical

Does your child have any severe allergies? (Ex. bee stings, food, penicillin, etc.)

Yes No

If yes, please list:

Is any medication being brought along with your child? (Ex. EpiPen, antibiotics, etc.)

Yes No

If yes, please list:

Are there any physical, emotional, or behavioral concerns or limitations we should be aware of?

Yes No

If yes, please explain:

Within the last three months, has your child been under a doctor's care?

Yes No

If yes, please explain:

Date of last Tetanus shot:

Please disclose any medical details we should be aware of, if any.

Alberta Health Insurance number:

Name of family physician:

Family physician phone number:

Emergency Contacts

Please provide at least one alternate contact we can reach in case of an emergecy, if the parent/guardian cannot be contacted.

Contact #1 Full Name:

Contact #1 Relationship:

Contact #1 Phone Number:

Contact #2 Full Name:

Contact #2 Relationship:

Contact #2 Phone Number

Waiver

I understand and agree that every precaution will be taken for the health and safety of the minor, but in the event of accident or illness, Victory Lutheran Church, its staff, and its volunteers are hereby released from any liability.

In the event that the minor requires medical attention, the parent/guardian will be notified immediately. The minor must be covered by Alberta Health Insurance or equivalent insurance.

I have read and understand this waiver.

Yes No

Signature of Parent/Guardian

Date

2024 Sunday School Registration, Medical Release, and Waiver Form

Description

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