Fort-2023-Student Waiver and Release Form

Student Name

Age

Birthdate

Cell Phone (N/A if None)

Address

Mother's Name

Mother's Email

Mother's Home Phone

Mother's Cell Phone

Mother's Address (if different from student)

Father's Name

Father's Email

Father's Home Phone

Father's Cell Phone

Father's Address (if different from student)

Insurance Company

Policy Number

Insurance Company Address

Group Number

Emergency Contact Name (other than parents listed above)

Emer. Contact. Phone

Physician Name

Physician Phone

Dentist Name

Dentist Phone

Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which you are subject and of which the staff should be aware, and what, if any, action of protection is required on account thereof.

Check the following areas of concern. If necessary, add another page with details:

For our safety and our knowledge, are you a--

good swimmer fair swimmer non-swimmer

Do you have allergies to--(please describe all that apply) pollens medications food insect bites Other

If you checked any of the allergy boxes, please elaborate

Do you suffer from, or have you ever experienced, or being treated for any of the following asthma frequently upset stomach epilepsy/seizure disorder physical handicap heart trouble handicap

Last Date of Tetanus Shot

Do you wear glasses contact lenses

Please list and explain any major illnesses that you have experienced during the last year

Additional comments

Should your activities be limited for any reason? Please explain?

Please list and explain any medications that your student will be taking during the trip. Include names of medications and dosages that must be taken.

Student Agreement

For your information, Atonement Lutheran expects each Student to conform to these codes of conduct:
No possession or use of alcohol, drugs, or tobacco
No fighting, weapons, fireworks, lighters, or explosives
No offensive or immodest clothing
Participation with the group is expected
Act in a Christian manner at all times
Respect property
Respect students, staff, and other adult leaders
Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home

I, the student, have read these rules of conduct, the above evaluation of my health, and permission to participate in activities. I agree to abide by the stated personal limitations and code of conduct.

Student Signature

Date

Parent Agreement

I permit my church named above to attend events sponsored by Atonement Lutheran Church (hereinafter the "Church")

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of liability against my personnel losses.

I understand there are inherent risks involved in any ministry or athletic event, and I hereby release the Church, its pastors, employees, agents and volunteer workers from any and all liability for any injury, loss, or damage to person or propert that may occur during the course of my involvement. In the event that my student is injured and require the attention of a doctor, I constent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event that treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information above is accurate at this date and will, to the best of my knowledge, still be in force for me. I also agree to bring my student home at my own expense should they become ill or if deemed necessary by the student ministries staff member.

Parent/Guardian Signature

Date

PRINT/SCAN/DROP OFF the Following Document

Please fill out form
-You can then sign it and scan back to kara@atonementmuskego.org and we will print

-Sign electronically and we will print

-Sign it and bring it to church and put in Kara's mailbox.

We MUST have this document to physically turn in to Fort Wilderness.

Find the form here, scroll down to Fort Form

https://www.atonementmuskego.org/youth

FORM

Upload (8MB)

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Fort-2023-Student Waiver and Release Form

Description

Please Fix the Following