PARENTAL CONSENT AND LIABILITY TO ACTIVITIES, MEDICAL,
DENTAL, OR HOSPITAL CARE FORM
I, ________________________, am the parent or legal guardian of _______________________
(hereinafter "my child"), who was born on ___________, _______, am informed of the activities offered by Beautiful
Savior Lutheran Church. The undersigned does hereby give permission for my child to attend __________________
___________________________________ and participate in activities sponsored by Beautiful Savior
_________________ (date) located at __________________________________________________.
I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care
under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon
licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination,
anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental
Practice Act for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment.
As parent or legal guardian of my child, I am responsible for the health care decisions of my child and am
authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the
dental, medical, or hospital care or treatment to be rendered to my child is legally sufficient and that no consent from
any other person is required by law.
Should it be necessary for our (my) child to return home due to medical reasons, or otherwise, the
undersigned shall assume transportation costs.
The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by
the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by
Beautiful Savior Lutheran Church.
I (on behalf of my child) do hereby assume all risk and release, forever discharge and agree to hold
harmless Beautiful Savior Lutheran Church, its officers and directors, employees and agents thereof from any and all
liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any
nature whatsoever which may be incur
red by the undersigned and the child-participant that occur while said child is participating in activities sponsored by
Beautiful Savior Lutheran Church.
The undersigned further hereby agree to hold harmless and indemnify said church, its officers and directors,
employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional
acts of said participant, including expenses incurred attendant thereto.
PHOTO RELEASE: I grant permission to BSLC to use my child’s photograph, likeness, image, voice or
performance in public forums including but not limited to marketing materials, our Internet website, Facebook page,
and Instagram. I understand that such images can be downloaded by any computer user.
Dated: __________________ , 2____________ .
___________________________________________
(SIGNATURE OF PARENT OR GUARDIAN)
______________________________
(HOME PHONE NUMBER)
___________________________________________
(PRINT NAME OF PARENT OR GUARDIAN)
______________________________
(CELL PHONE NUMBER)
Additional Information:
My child is to be excluded from the following activities: _______________________________________