Parent Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Medical Waiver *

By checking the I Agree box, you authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and all other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for your child(ren) and waive your right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

I Agree

Photo Release

By checking the I Agree box, you hereby give permission for your child(ren) to be photographed and to have photos posted on Messiah Lutheran Church website, in newspapers or invitations, without names listed. This is optional.

I Agree

I Do Not Agree