Grace Evangelical Lutheran Church
216 N. Wooster Ave. Dover, OH 44622
330-343-6915 gracehappens@gracedover.org
Event: _____________________________________________________________________________
Name of Youth: ______________________________________________________________________
Name of Parent/Guardian: ______________________________________________________________
Address: ___________________________________________________________________________
Phone #: _______________________________ Alternate Phone #: _____________________________
Emergency Contact: __________________________________________________________________
Relation to Youth:____________________________________________________________________
Phone #: _______________________________ Alternate Phone #: _____________________________
Family Doctor: ________________________________ Phone #: ______________________________
Insurance Company: _________________________________________________________________
Phone #: _______________________________ Policy #: ___________________________________
Food Allergies: _____________________________________________________________________
Medicine Allergies: __________________________________________________________________
Youth may be given: Aspirin: Yes No Advil: Yes No Tylenol: Yes No
Any conditions that would limit ability to participate fully in activities?
I, the legal
parent/guardian (print name) ______________________________, of the above named
youth, give my consent for him/her to attend this event.
I also give consent for administration of
normal first aid in the case of
accident or illness while attending, traveling to, and from the event.
I further give my consent to seek emergency care for him/her if
necessary, and for authorized
personnel to provide whatever emergency care
deemed necessary. I hereby release
the
guides/leaders, and Grace Evangelical Lutheran Church from liability in
carrying out the above
procedures.
Parent/Guardian Signature: _____________________________ Date:_____________