SM Challenge Consent Form

Registration and Medical Consent Form - Lake Community Church

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.

Student Name *
Student Name
Date of Birth *
Date of Birth
Gender *
Phone (student #) *
Phone (student #)
Parent Name *
Parent Name
Parent Cell # *
Parent Cell #
Additional Parent Name (optional)
Additional Parent Name (optional)
Additional Parent Cell # (optional)
Additional Parent Cell # (optional)
Emergency Contact Person *
Emergency Contact Person
Not parents in the event that parents listed above are not available.
Emergency Contact Phone *
Emergency Contact Phone