St Paul Lutheran Church Release of Liability Form
181 S Santa Clara New Braunfels, TX 78130
Contact Information Dependent Name Address City State Zip Home Phone # Date of Birth Parent Information Parent/Guardian Work Phone Cell Phone Doctor’s Name Office Phone Emergency Contact Information (if parent/guardian cannot be reached) Contact Name & Phone # Address City State Zip Work Phone Hospital and Insurance Information Hospital Preference Insurance Info (Attach copy of front & back of card) Insurance Company Group # Member # Health History Please list any Special Medical Conditions Date of last Tetanus Shot Medications to be taken (list with directions) Medication Name
I hereby request and give permission for the staff of St Paul Lutheran Church and their volunteers to administer the medications listed above and over the counter medicine to the student named on this form. I understand it is my responsibility to provide the prescription medication. I also understand that all medications must be provided in the original pharmacy containers. I understand my child is responsible for reporting to the staff and volunteers at appropriate times to receive their medications. Parent Signature_______________________________ Date _____________________________________ Medication Allergies Food Allergies
(Please list all allergies to medicines)
I give permission for my child to receive (Please check the items that are approved)
Transportation Release (applies to students only)
Discipline Release (applies to students only)
I give permission for my youth to be transported to and from church
In the event of misconduct, I authorize the staff and volunteers to send
sponsored activities in a church, rental, or private vehicle.
Insurance Release (applies to all traveling)
Personal Belongings Release (applies to all traveling)
I realize the church insurance begins where the individual health and
I realize that the church, its staff and volunteers are not responsible for
accident policy terminates. It is only valid when all other insurance has
been extended to its limits. I also understand that there is no assurance
that any particular situation or event will be covered for loss.
General Release I hereby give consent in advance to the designated Youth Leaders and the volunteers of St Paul Lutheran Church and to the physicians or hospitals selected by them to render first aid treatment or deny treatment as in their judgment is reasonably necessary, including, but not limited to, hospitalization, diagnosis including taking specimens, and x-rays, giving blood transfusions, and medications, anesthesia, and surgery for my dependent listed above. I understand that the Youth Leaders of St Paul Lutheran Church will attempt to contact me before securing treatment, but that this consent is given in case I am not available in an emergency. I release all Youth Leaders and staff affiliated with St Paul’s from any and all claims, loss, cost, damage, or expense arising out of or from any accident or other occurrences causing injury to an person or property. Parent Signature ______________________________ Date ______________________________________
This form must be notarized in order for your youth to travel and participate in the youth activities for St Paul Lutheran Church. Parent Signature _______________________ Date ______________________________ On _________________ before me, ___________________________ personally appeared _______________________________________ personally known to me or proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person acted, executed the instrument. WITNESS my hand and official seal.
Notary Signature ______________________ Date _______________________________
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DIRECCIÓN GENERAL DE RADIO, TELEVISIÓN Y CINEMATOGRAFÍA DIRECCIÓN DE CONTENIDOS Y DISTRIBUCIÓN DE SEÑALES DE RADIO Y TELEVISIÓN SERIES AUTORIZADAS, MAYO 2007 SERIES, DOCUMENTALES DIRECTOR ACTORES PRINCIPALES REALIZACION CONCESIONARIA AUTORIZACIÓN JIMMY NTINTILI, DES DEMPSEY, JOEL STEWARTMICHAEL SHEEN, CATHERINE McCORMAK, JAMES WILBY, BEN MYRA DENISE STEPHERSON