Consent Form Service Project

    I authorize that my child is granted full permission to participate in the events and activities organized by the Student Ministries of Lake Community Church.
    I understand that possible risks and dangers may be encountered on any given trip or event, and I the parent, trust the judgment of Lake Community Church, its pastors and staff, and volunteer leaders.  In the event of an emergency or injury to my child, I grant permission to Pastor Paul Peterson or a volunteer leader to seek appropriate medical attention for the injury to my child including visits to the emergency room or a doctor, X-Ray examinations, anesthetic and/or other medical/dental needs.  In the event of an emergency or injury, the church representative, staff or volunteer will first attempt to contact and consult with the parents and/or emergency contact person provided on this form, and will only continue to seek medical attention without parental consultation if the parent or emergency contact cannot be reached and if the situation is deemed necessary or extremely urgent.
    Understanding the above notice, I release Lake Community Church, its pastors and staff, volunteer leaders, and any event staff/volunteers from any and all liability claims for sickness, expenses, damages, medical services and injury, even injury resulting in death.

Event Name:  Service Project Day - making bunk & toddler beds or Serving at Someplace Safe Thrift Store

Effective Date:  Friday, July 18, 2014

Location:  Lake Community Church and Someplace Safe Thrift Store

Student Information *
Student Information
Address *
Date of Birth *
Date of Birth
Student Cell # *
Student Cell #
Parent Information
Parent Information
Mother's Cell Phone *
Mother's Cell Phone
Father's Cell Phone *
Father's Cell Phone
Emergency Contact Person (other than parents) *
Emergency Contact Person (other than parents)
Phone *
Insurance Provider
I certify that I am the parent or guardian registering the above listed student *