LakeView Church Student Participation Form

Liability waiver

• I/We understand that in the event medical intervention is needed while under the care of LakeView Church, every attempt will be made to contact immediately the persons listed on this form. In the event I/We cannot be reached, I/We hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order an injection, anesthesia, or surgery for the student(s) as deemed necessary.

• I/We further agree to hold the licensed physician, the medical facility, LakeView Church and its representatives free and harmless of any claims, demands or suits for damages arising from the authorization and provision of such medical treatment.

• I/We understand the nature of the event and do hereby release LakeView Church and its representatives from any liability due to accident or injury incurred by my child(ren).

• I/We understand all reasonable safety precautions will be taken at all times by LakeView Church Student Ministries and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold LakeView Church and its representatives liable for damages, losses, diseases, or injuries incurred by the subject of this form.

• I/We agree to cover all costs if our student(s) needs to be sent home for disciplinary reasons.

• Unless otherwise noted, signing this form will release to LakeView Church the rights to photos, video or other images of this student(s) for use in church publications.

Student Name *
Student Name
Cell Phone
Cell Phone
Date of Birth *
Date of Birth
Gender *
For example: 12
Allergies, medical concerns, disabilities, special needs etc.
Parent/Guardian Name *
Parent/Guardian Name
By typing my name here, I am giving permission for my child to go with the Stoughton LakeView Church gouth group on any outing that they have signed up for. I agree with the waiver below.
Parent/Guardian Phone *
Parent/Guardian Phone
Emergency Contact *
Emergency Contact
Emergency Phone *
Emergency Phone
Doctor Phone *
Doctor Phone