Child's Name *

First Name

Last Name

Parent/Guardian Name *

First Name

Last Name

Phone

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Name *

First Name

Last Name

Phone

(###)

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Permission *

I give permission for my child to participate in Lutheran Church of the Good Shepherd activities under the supervision and direction of the Lutheran Church of the Good Shepherd staff and other designated volunteers. I release Lutheran Church of the Good Shepherd from liability should my child be injured in any way while participating in activities. I give permission for leaders to take whatever steps may be necessary to obtain emergency medical care as warranted. These steps may include, but are not limited to, the following: 1. Attempt to contact a parent or guardian 2. Seek medical examination and treatment for injuries or conditions by a medical professional. I understand that it is my responsibility to resubmit this form if any changes occur regarding the health of my child, and that any expenses incurred in necessary emergency medical treatment will be paid by the child’s coverage or the family. I give permission for my child’s image to be used in any Lutheran Church of the Good Shepherd publications, slide shows, and website.