Liability/Medical/Media Release for Youth

In consideration for the undersigned child being accepted by First Lutheran Church of Sioux Falls, South Dakota, for participation in youth trips/activities, we, being the parent(s) or legal guardian(s) of the undersigned child, do release and agree to hold harmless First Lutheran Church of Sioux Falls, South Dakota, and its chaperones, employees, agents, representatives, and board members from any and all liability, claims, damages, or demands for personal injury, as well as damage and expenses (including reasonable attorneys fees), of any nature that may be incurred by the parent/guardian and child/participant while the child is participating in the above described trip or activity or in connection with or resulting from such trip or activity, including transportation to and from the above described trip or activity.

We, on behalf of the undersigned child, assume all risk of personal injury, damage, and expense as the result of participation in and transportation to and from such trip/activity.

We give our permission to First Lutheran Church to furnish any necessary transportation, food and lodging for the undersigned child and for him/her to participate fully in such trip/activity and give our permission and consent to transportation of the undersigned child to a doctor, hospital, or other medical provider and authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.

Should it be necessary for the undersigned child to return home due to medical reasons, disciplinary action, or otherwise, we assume and agree to be liable for and pay all transportation costs.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I MAY BE GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. I INTEND THIS AGREEMENT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD INVALID, THE BALANCE SHALL CONTINUE IN FULL FORCE AND EFFECT.

Your name *

Email address *

If you do NOT want to have pictures/video used, please check this box.

I otherwise grant First Lutheran Church use of pictures/video of my child involved in educational and fellowship activities planned by
our church. These pictures could be displayed on our website, in the church, or as part of publications.

Child Name *

Please include first and last name.

Child's Date of Birth *

Parent/Guardian Name *

Please include first and last name.

Parent/Guardian Name

Please include first and last name.

Address *

Please include full street address, city, state, and zip.

Parent/Guardian Phone Number *

Please include area code.

Additional Emergency Contact Name *

Please include first and last name.

Additional Emergency Contact Phone Number *

Please include area code.

Relation to Child *

Do you have medical insurance? *

Insurance Company Name

Policy #

Physician Name, Clinic/Hospital

Please include as much detail as possible.

Does the child have any allergies, required medications, or other needs we should be aware of? If yes, please explain. *

First Lutheran Church Youth Protection Standards of Conduct

BEHAVIOR POLICY
*Any abuse (physical, emotional, sexual, verbal) will not be tolerated at any First Lutheran Church activity.
*Any abusive conduct or allegation will lead to immediate removal of individual in question until a confidential review is conducted.

PREVENTION GUIDELINES
*Focus your actions on these spiritual guidelines:
Ephesians 4:32 Be kind and compassionate to one another, forgiving each other, just as in Christ, God forgave you.
I Peter 5:5 All of you, clothe yourselves with humility toward one another, because, “God opposes the proud but gives grace to the humble.”
Matthew 17:20-21 I tell you the truth, if you have faith as small as a mustard seed, you can say to this mountain, “Move from here to there” and it will move. Nothing will be impossible for you.

*Do not put yourself in a compromising situation. Be careful where you meet.
*Do not rely on your good reputation. Do not put yourself in a position where it’s your word against another person’s.
*Be aware of what you say. Refrain from words and phrases that are abusive, or that could be misleading to individuals receiving or watching.
*Watch what you do. Be cautious and avoid inappropriate or uncomfortable touch. Avoid actions that could be misleading to individuals receiving and those watching.

Parents: I have read and agree to the above policies. *

Please type your first and last name.

Student: I agree to follow the guidelines. *

Please type your first and last name.

Today's Date *

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