2025-26 Emergency Form - Minor

If your child is planning on participating in any of our programs, please fill out this Emergency Form. Thank you for helping us keep everyone safe. This form is effective through July 31, 2026.

Your name *

Email address *

Phone number *

Name of Minor *

Please type the full name of the minor this form is being filled out for.

Youth cell number

Please answer if youth is 13+ years old.

Phone number

Grade for 2025/26 School year

Grade *

Gender *

Birthdate *

Insurance info

Immanuel Lutheran Church does NOT carry health insurance on participants/members/friends. Any cost resulting from an illness or injury is the sole responsibility of the parent/guardian. In the event of an emergency and the parent/guardian or the emergency contact is unable to be contacted, the Immanuel Lutheran Church representative may authorize medical treatment for my child.

Insurance Information *

Name of your Insurance and Subscriber ID number.
If you currently have no insurance, please type "NONE".

Name of Family Physician *

If none, please type "NONE".

Emergency Contact *

If parents can not be reached.
Please include Name, Relationship to child, and phone number.

Alergies or Medical Concerns *

If none please type NONE

Release Information *

My child may be independently released after all classes and/or activities (this means they can leave the classroom and/or building). We DO NOT monitor the parking lot. If you select NO they must wait to be picked up inside the building.

Yes, my child may be independently released.

No, my child may NOT be independently released.

PARTICIPATION AGREEMENT/MEDICAL RELEASE

By submitting this form, parent(s) or legal guardian(s) this minor, do here by authorize Immanuel Lutheran Church as agent for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis, or treatment and hospital care of service, which is deemed advisable and is to be rendered to said minor, under the general or specific supervision of any physician and surgeon licensed, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being rendered, but is given as specific consent to any and all such diagnosis, treatment, or hospital care which the above mentioned physician, in the exercise of his/her best judgment, may deem advisable to protect the life and health of said minor child. This authorization is given, and shall remain in effect from signature date for ONE YEAR, unless sooner revoked in writing and delivered to said agents. I acknowledge that participation in the activity described above involves risk to the Participant (and to Participant’s parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in the activity described above (the “Activity”), the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the Activity. The Participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the Activity or during transportation to and from the activity, as well as for any medical treatment rendered to the Participant that is authorized by the Sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “Activity Sponsor”). Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Activity Sponsor for any injury arising directly or indirectly out of the described Activity or transportation to and from the Activity, whether such injury arises out of the negligence of the Activity Sponsor, the Participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.

IMPORTANT PHOTOGRAPHY, VIDEO, AND WEB PUBLISHING INFORMATION

Immanuel Lutheran members/students/friends/participants may be photographed or videotaped, and their name and/or work displayed for educational and/or not-for-profit use in various ways: newsletter articles, community newspaper articles, building videos, rosters, as well as building, and web pages, etc. If you DO NOT want your child to participate in the aforementioned activities, submit your request in writing to Immanuel Lutheran Church.