2021-2022 St. Mark's Medical Release Form
ST MARK’S LUTHERAN CHURCH BY THE NARROWS
6730 N. 17th St., Tacoma, WA  98406
253-752-4966
office@smlutheran.org 

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PARENTAL CONSENT AND RELEASE OF ALL CLAIMS
In consideration for being accepted by St. Mark’s Lutheran Church by The Narrows for participation in all St. Mark’s Youth Events, we(I) being eighteen years of age or older, do for trip/event ourselves(myself) and for and on behalf of our(my) child-participant, if said child is not eighteen years of age or older, do hereby release, forever discharge and agree to hold harmless St. Mark’s Lutheran Church by The Narrows, the directors 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 incurred by the undersigned and the child-participant that may occur while said child is participating in the above described trip.  

Furthermore, I(we) (and on behalf of our child-participant if under the age of 18 years) hereby assume all risk of personal injury, sickness, death or damage as a result of participation in recreational and work activities involved therein.  The undersigned further hereby agree to indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant.  

We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in said trip, and hereby give our (my) permission to take said participant to a physician or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.  Further, should it be necessary for the participant to return home due to disciplinary action, for medical reasons or otherwise, we (I) hereby assume all transportation costs.
Name of Participant *
Contact Number for participant: Home (h) and Cell (c)--please indicate which *
If over 18 years of age please check here: by doing so you acknowledge that you might be asked to submit a Washington State Patrol Background check.
TRIP PARTICIPANT ONLY: I have read the foregoing and understand the rules of conduct for participants and will abide by them as well as the directors of the leadership of the trip. *
Required
PARENT/GUARDIAN(S) or PARTICIPANTS over 18 years OF AGE: By checking this box I ACKNOWLEDGE the above hold harmless statement and release of claims. *
Required
If student is under 18, both parents must be listed unless parents are separated , divorced or student comes from a single parent household, in which case the custodial parent must complete and list name and contact information.
Parent/Guardian:
Parent/Guardian Primary Contact Number: please indicate cell (c) or home(h)
Parent/Guardian:
Parent/Guardian Primary Contact Number: please indicate cell (c) or home(h)
2021-2022 PARTICIPANT MEDICAL QUESTIONNAIRE
Please be as complete as possible
Participant's Full Legal Name: *
Date of Birth: *
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Physical Address: *
Are you currently being treated by a doctor for any condition?   If yes, please explain:
Are you currently taking any medications or prescription drugs? If yes, please name the medication, give dosage, frequency, and how administered.
Are you affected by any of the following? If yes please indicate which and explain as you are able to:
Heart Condition; Cramps; Asthma; Nosebleeds; Diabetes; Allergies: Food, Seasonal or Environmental; Fainting/Dizziness
Do you have allergic reactions to any insect bites (mosquito, bee, wasp, etc.)?
Food allergies or sensitives:
Do you carry medication/epi pen for any of the above allergic reactions?
Clear selection
Do you know of any condition which would affect your ability to participate in strenuous outdoor activity?  If yes, please explain:
Last Tetanus Shot date: *
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Dietary Restrictions *
Explanation(s) for any Dietary Restrictions:
MEDICAL INSURANCE INFORMATION:
Please provide a copy of participants insurance card if available: can be emailed to ingelaurie@smlutheran.org 
Insurance Company: *
Policy Number: *
Participants Physician: *
Physicians Number: *
IN CASE OF AN EMERGENCY
PLEASE CONTACT THE FOLLOWING:
Name and Relationship to Participant: *
Contact Number: Home(h) and Cell (c) *
Physical Address: *
IF PARENT/GUARDIAN OR THE ABOVE CAN NOT BE REACHED:
Please contact the following:
Name and Relationship to Participant: *
Contact Number: Home (h) and Cell (c) *
Any other information the leaders need to be aware regarding the participant?
Submit
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