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* 1. Child's Name

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* 2. Which Life Church Campus does your family attend? 

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* 3. Grade for 2018-19 school year

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* 4. What is your child's birthday?

00/00/0000

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* 5. Parent/Guardian Information

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* 6. Please list any allergies the child may have

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* 7. Please list any physical, mental, or social conditions which need to be monitored

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* 8. How should we respond to this condition?

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* 9. Emergency Contact information

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* 10. I, the undersigned, have legal custody of the child named above, a minor, and have given my consent for my child to attend events being organized by Life Church Assembly of God, Inc. (“Church”). The Church includes its Pastors, employees, agents, and volunteer workers. I understand and consent that my child may be taught Biblical principles.
* Medical Consent: If my child experiences a medical situation, and I or my emergency contact cannot be reached, I give my permission to seek whatever medical attention is deemed necessary by the Church, and transport my child by ambulance or private vehicle to the nearest medical facility. In the event that my child is injured and requires medical services, I consent to any medical treatment as deemed necessary by a licensed physician. I also acknowledge that I will be ultimately responsible for the cost of any medical services should the costs not be reimbursed by any health insurance provider. I release the Church from any and all medical services and costs.
* Release: I understand that there are inherent risks involved in any ministry or activity, and I hereby release the Church from any and all liability, loss, or damage to person or property that may occur during the course of my child’s involvement. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold the Church free and harmless of any and all liability, claims, demands, or suits for damages arising from the giving of such consent.

My name and date below serve as my electronic signature to this medical release form for my child.

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