In addition to completing this form, please provide photos of the back and front of your health insurance card to Donna Snyder (email to firstname.lastname@example.org, put in envelope in secure dropbox by office door, or hand to her directly).
Participant's Name (required)*
Date of Birth*
If the church office already has the following, please skip to 'Emergency Contact Information'.
Emergency Contact Information*
Health Insurance Information
Name on Insurance*
Employer (if applicable)
Group or Plan#
Allergies to medication, food, insects, or environment
Please describe symptoms/severity of allergy
Please list any health conditions, illnesses, or injuries of which we should be aware (hypertension, diabetes, heart defect/disease, etc.)
I understand that participants must be in good health when arriving at an event. If a participant is found to have a fever, head lice, or unexplained rash, the participant will be asked to go home
Please enter your full name to indicate your permission*:
For the time period of this event, I do hereby authorize approved adult leaders of Cross of Life Lutheran Church to consent to any medical treatment, dental treatment, or hospital care to be rendered to me under the general or specific supervision and on the advice of any licensed physician, dentist, or surgeon. It is my understanding that if the nature of the emergency allows for the time or opportunity, attempts will be made to contact my emergency contact at the phone numbers provided above before any treatment by physician, surgeon, dentist, or surgeon, or hospital. I understand that in the event I am injured or become ill and it is necessary for me to receive medical or dental treatment, that my health, dental, and accident insurance will be used to cover such expenses and that I will be responsible for any such expenses not covered by my insurance.