St. Luke’s
United Methodist Church (together with their respective officers, employees and
agents) and each volunteer assisting them are collectively designated by the abbreviation
"St. Luke’s" throughout this entire form and the term "St. Luke’s"
shall refer to them individually as well as collectively.
Medical Consent:
•
Consent for Minors: I hereby authorize St. Luke’s to take my child for medical treatment in
the event of an illness or injury in which a parent cannot be reached after a
reasonable attempt to do so.
• I do hereby authorize any physician, dentist, hospital or medical treatment
center to treat my child in the case of emergency. The undersigned adult shall
be liable and agrees to pay all costs and expenses incurred in connection with
such medical and dental services rendered to the aforementioned individual
pursuant to this authorization.
• I hereby authorize St. Luke’s
to consent to any x-ray examination, anesthetic, medical, surgical, or dental
diagnosis or treatment, and hospital care to be rendered to me or my child
under the general or special supervision and on the advice of any physician or
dentist representing to be licensed on the medical staff of a hospital or
medical care facility, whether such diagnosis or treatment is rendered at the
office of said physician or at the said facility or hospital.
• I hereby do authorize St. Luke’s
to dispense to my child any over-the-counter medications (according to proper
dosage instructions) when deemed reasonably necessary.
Activity/Event Consent
•
I hereby give permission my child to attend and participate in activities
sponsored by St. Luke’s
and/or its’ ministries.
• I authorize St. Luke’s
to include my child in routinely supervised water activities.
• I hereby assume all risk of personal injury, sickness, death, damage and
expenses as a result of participation in recreation and physical activities
involved therein for my minor child.
Liability Release
•
I hereby release, forever discharge and agree to defend and hold harmless St. Luke’s from any and all liability, claims or
demands for personal injury, sickness or death, as well as property damages and
expenses, of any nature whatsoever which may be incurred by the participant
that occur while said individual is participating in any trip or activity with St. Luke’s.
• The undersigned further hereby agrees to hold harmless and indemnify St. Luke’s from and against any claim against or loss
incurred by St. Luke’s
as the result of the negligent, willful or intentional acts of my child,
including any expense incurred attendant thereto.
• I acknowledge and agree that it is my responsibility to notify St. Luke’s of any changes in medical condition,
guardianship, address or telephone, in writing to the address listed on this
form.
• The medical consent, activity/event consent and waiver provisions hereof
shall remain in full force and in effect until the VBS event is completely over
on June 10th.
Disclosure
•
By signing here electronically, I verify I have read and consent to everything
above. I give Permission for my child to attend VBS and for his/her photo to be
taken and used in church publications.
