PARENTAL CONSENT, CERTIFICATION, AND MEDICAL AUTHORIZATION

Faith Lutheran Church, Eldridge, Iowa (563) 285-4501

Parents and legal guardians of minor children are asked to complete this form and return it to the church. The information is designed to assist the church in providing for the safety of minors during church sponsored activities.

General Information (please print)

Child’s Name___________________________________________ Date of Birth_____________

Father’s Name ___________________________ Mother’s Name ________________________

Child’s Address________________________________________________________________

Home Phone No _________________Parent’s Work Phone No. _____________Cell No._______

Family Doctor__________________________________ Doctor’s Phone No.________________

Insurance Company Covering Child ______________________________Policy No. ___________

Consent and Certification

I, the undersigned, being the parent or legal guardian of the child named above (the “child”), do hereby consent to the participation of my child in all of the regularly scheduled activities of all programs for youth of Faith Lutheran Church, Eldridge, Iowa, (“Church”) for the period of September 1, 2003 through October 31, 2004, including field trips, campouts, swimming, boating, hiking, sporting events, retreats and any other activities customarily associated with church youth programs. Further, I certify that my child is physically fit and adequately trained to participate in such events, including swimming, except as noted below:

Parent/Guardian Signature:______________________________________ Date:_________

MEDICAL QUESTIONNAIRE

Is your child presently being treated for an injury or sickness or taking any form of medication for any reasons? Yes_____ No_____ (If yes, please explain)

___________________________________________________________________________

Does your child have any allergies (including medications)? Yes____ No_____ (If yes, please explain)

___________________________________________________________________________

Does your child ever sleep walk? Yes____ No_____ Can your child swim? Yes____ No

___________________________________________________________________________

Does your child have any physical condition or illness that would prevent him or her from participating in the regularly scheduled activities described above or in any other rigorous activity? Yes_____ No_____ If yes, please explain below. A written release must be submitted by child’s physician authorizing your child to participate in such activities.

___________________________________________________________________________

Does your child require a special diet? Yes____ No____ (If yes, please explain)

___________________________________________________________________________

(over)

MEDICAL TREATMENT AUTHORIZATION

I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I authorize any adult supervisor to make emergency medical decisions on behalf of my child if such decisions are required by law or deemed necessary or advisable by a health care provider. I understand that the Church and the persons named above will not be responsible for medical expenses incurred solely on the basis of this authorization.

I agree to notify the Church in the event of any health changes which would restrict my child’s participation in any normal youth or children’s activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.

Parent Signature_____________________________________ Date_____________________