Liability Waiver And Release & Medical Consent Form


IMMANUEL LUTHERAN CHURCH & SCHOOL
200 NORTH PLUM GROVE ROAD, PALATINE, ILLINOIS 60067
Phone (847) 359-1549  Fax (847) 359-1583
ANNUAL LIABILITY WAIVER AND RELEASE & MEDICAL CONSENT FORM – Minor Child Under Age 18



A parent or guardian of each Immanuel Lutheran Church & School (ILCS) student or minor child that wishes to participate in any on-site or off-site field trip, overnight trip, special event, extracurricular program or activity including, but not limited to, athletic programs, fine arts programs, extended school supervision program, and summer camp programs organized or sponsored by ILCS must complete the following Liability Waiver and Release & Medical Consent Form before his/her student/child may begin participation. This Liability Waiver and Release & Medical Consent Form needs to be completed annually for each student/child and is valid from the date signed through August 31, 2016.

 

PERSONAL INFORMATION of the Student/Child

Is the Student/Child an

 

Name:     Gender:

 
Street Address:
City:         State:   Zip:   
Birth Date:    Age:    Class/Grade: 
Home Phone:    Cell Phone:    Work Phone:   

 

TRIP, EVENT, PROGRAM/ACTIVITY INFORMATION

The above named student/child has permission to participate in (as grade applicable) the following activities held annually at Ost Field in Palatine: Mile Run (Grades 3 – 8), Field Days (Full Day PreSchool - Grade 8), and Walk-a-Thon (Full Day PreSchool - Grade 8). Information outlining the specifics (date, time, meals…) of each Ost Field activity will be provided throughout the year. A separate registration and/or permission form will be required for any additional field trip, special event, program, or activity a student/child may participate in during the year; these materials will outline the specifics of each additional trip, event, program or activity such as location, date, time, fees, meals, housing, transportation, and chaperones.

 

MEDICAL INFORMATION

Check the appropriate box if the student/child has ever had any of the following; please explain under remarks

Remarks:

Health Insurance Provider:     Policy Number:   
Family Doctor:    Office Phone:   
Family Dentist:   Office Phone: 

 

IN CASE OF EMERGENCY CONTACT

Name:    
Relationship to Minor:
Street Address:   
City:    State:   Zip: 
Home Phone:    Cell Phone:     Work Phone: 

 

PUBLICITY RELEASE AUTHORIZATION

I understand photos, videos and sound recordings of students and children may be used on the Immanuel website, yearbook, brochures or other such media for the purpose of public relations, promotion of Immanuel events, recruitment, student records, historical records or other activities that serve to publicize Immanuel Lutheran Church & School. I further understand that all photos, videos and sound recordings will be taken in a public venue and will not offend Christian or civil standards, and that no written identification of any individual student/child will accompany photos, videos, or sound recordings other than those used for student and historical records. I authorize Immanuel Lutheran Church & School to take photos, videos, and produce sound recordings of the above named student or child and to use such photos, videos and sound records as follows (please initial one of the following three options):



 

LIABILITY WAIVER RELEASE & MEDICAL CONSENT

In consideration of being allowed to participate in the Trip, Event, Program or Activity sponsored by Immanuel Lutheran Church & School, Palatine, IL; and in consideration of the benefits derived therefrom, I on my behalf and, if applicable, on behalf of the Minor named on the reverse side (the “Minor”) hereby release the Northern Illinois District, the Lutheran Church-Missouri Synod, Immanuel Lutheran Church & School and their present and former trustees, officers, directors, boards, shareholders, employees, agents and their heirs, administrators, executors, successors, and assigns from all demands, actions, suits, proceedings, damages, claims and liabilities of any kind, whether known or unknown, which arise from or are connected with my or the Minor’s participation in the event.
I am aware that in addition to typical activities such as Bible study, worship, sight-seeing, using public transportation, and meal functions; that I or the Minor may participate in various other activities that may involve some risks, such as service projects and recreational activities. I have read the informational materials about this Event and the site and understand the risks involved in the planned activities. I recognize that the conditions, equipment or standards in some of the places which I or the Minor will travel may not be of the same quality level or standards as the conditions, equipment or standards to which I am accustomed. I realize further that there are certain health risks as well as other risks to me or the Minor and our property. I enter into participation in this Event with knowledge of those risks and acceptance of responsibility for any harm, injury or damage resulting therefrom. If for any reason I am unable to complete my stay at the Event, I assume full responsibility for expenses incurred for my return home.
In the event of an emergency, I hereby authorize a leader of this activity, as an agent for me or the Minor, to consent to: any x-ray, examination; medical dental or surgical diagnosis; treatments; hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state or country where services are rendered, either at a doctor’s office or in a hospital. I expect to be contacted or my family contacted as soon as possible.
I understand that this document constitutes a full and complete waiver & release of any & all possible claims for any act or omission, including claims for negligence regarding injury or property damages, arising out of my or the Minor’s participation in the Event.
I understand that this release applies to, covers, and includes unknown, unforeseen, unanticipated, and unsuspected risks, damages, losses, or liabilities and the consequences thereof, which result from the matters herein before inferred to as well as those not disclosed and known to exist. The provisions of any state, federal, local or territorial law or statue providing in substance that releases shall not extend to claims or damages which are unknown or unsuspected to exist at the time are hereby expressly waived by me.
Furthermore, I do hereby expressly stipulate, and agree to indemnify and hold forever harmless the Northern Illinois District, the Lutheran Church-Missouri Synod, Immanuel Lutheran Church and School, and their agents, servants, successors, assigns, boards, directors, trustees, officers, employees, and other representatives against loss from any and all present or future claims, demands or actions in law or in equity that may hereafter be made or brought by me or the Minor or on our behalf, related to or resulting from any occurrence, act or omission during the Event, or travel to and from the Event.
I also hereby release and waive any and all claims for liability against any of the host churches, host institutions and the employees, agents, officers, directors, shareholders, contractors and assigns of such host church or host institution or the owner of any sites that I or the Minor may be at during the Event.
By acceptance of participation in the Event, the undersigned agrees to the foregoing and also agrees that the Northern Illinois District, the Lutheran Church-Missouri Synod, Immanuel Lutheran Church & School, and their employees and other representatives, shall not be liable for loss, damage, injury or inconvenience caused by or resulting from the malfunction of transportation, equipment, strikes, acts of war or insurrection, fire, delays, theft or itinerary or schedule changes or cancellations.
I certify that I am of lawful age and competent to sign this Release, or that I have all right, power and authority to do so on behalf of the Minor, that I understand its contents and that I have signed this release voluntarily.
I certify the information provided on the reverse (Page-1) of this document is correct and I have read the LIABILITY WAIVER RELEASE above and understand its contents. I agree to its terms and sign this of my own free act and deed.

 

Minor Participant’s Printed Name: 

 

Parent / Guardian Name: 

Relationship to Minor:   

Street Address:   

Street Address 2:   

City:     State:    Zip:   

Phone:   

 

PLEASE REVIEW THIS FORM BEFORE SIGNING
Immanuel Lutheran Church & School, 200 North Plum Grove Road, Palatine, IL 60067
Phone (847) 359-1549  Fax (847) 359-1583

Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Liability Waiver And Release & Medical Consent Form
lock iconUnique Document ID: 8a8163a2b8da70c65c5ed28e69b779f6d38497c6
Timestamp Audit
2016-01-24 20:24:56 CDTLiability Waiver And Release & Medical Consent Form Uploaded by ILCP - Immanuel Lutheran Church & School - esignature@ilcp.org IP 104.129.196.126
Audit trial Qr code
This audit trail report provides a detailed record of the online activity and events recorded for this document.
http://www.immanuelpalatine.org/
Audit Trail Serial# 865f8a5cc4bdd02d9562bbca45744c06