Mt. Calvary Emergency Form

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PLEASE PRINT CLEARLY AND READ THE BACK OF THIS FORM BEFORE SIGNING



PLEASE PRINT CLEARLY AND READ THE BACK OF THIS FORM BEFORE SIGNING











 Allergies (including drug)
 Asthma
 Bee/Wasp Reaction
 Diabetes
 Dizziness/Fainting
 Epilepsy
 Hay Fever
 Heart Condition
 High Blood Pressure
 Operation in last year
 Penicillin Allergy
 Physical Handicap
 Regular Medication
 Respiratory Problems
 Seizures
 Allergic to Poison Ivy/Oak/Sumac
 Other: ______________________

MOUNT CALVARY LUTHERAN CHURCH
LIABILITY RELEASE AND MEDICAL CONSENT FORM
PERSONAL INFORMATION
MEDICAL INFORMATION

PERSONAL INFORMATION
IN CASE OF EMERGENCY CONTACT
MEDICAL RELEASE
Name: _____________________________________________________ Birthdate: ____________ Sex: Male Female
Address: ________________________________________ City: ___________________ State: _________ Zip: __________
Home Phone: ___________________________ Cell: ___________________________
Check the appropriate box if you have ever had any of the following and please explain under remarks.

Name: _____________________________________________________ Relationship: __________________________________
Address: ________________________________________ City: ___________________ State: _________ Zip: __________
Home Phone: ___________________________ Cell: ___________________________
REMARKS: _______________________________________________________________________________________________________________
Date of Last Tetanus Shot: _______________________________
Health Plan Carrier: _____________________________________ Policy Number: _____________________________________
Family Doctor: _____________________________________ Phone Number: _____________________________________
Family Dentist: _____________________________________ Phone Number: _____________________________________
I certify that the above information is correct and I have read the LIABILITY WAIVER AND RELEASE on the
reverse side and understand its contents. I agree to its terms and sign this of my own free act and deed.
In an emergency, I do hereby give my permission to employ physicians, surgeons, dentists, nurses, and other health
care personnel as may be deemed necessary to hospitalize, anesthetize, diagnostically test, or perform surgery.

Signature: _________________________________________ Print: _______________________________________ Date: ______________

Parent/Guardian Signature (If under 18 years old): _______________________________________________
Parent/Guardian Print (If under 18 years old): _______________________________________________
PLEASE PRINT CLEARLY AND READ THE BACK OF THIS FORM BEFORE SIGNING



PLEASE PRINT CLEARLY AND READ THE BACK OF THIS FORM BEFORE SIGNING
Liability Waiver, Release, and Authorization To Consent Form – Page 2
In consideration of being allowed to participate in the Event sponsored by Mount Calvary Lutheran Church,
Janesville,WI; and in consideration of the benefits derived therefrom, I on my behalf and, if applicable, on behalf of
the Minor named on the reverse side (the “Minor”) hereby release the Southern Wisconsin District, the Lutheran
Church-Missouri Synod, Mount Calvary Lutheran Church and their present and former trustees, officers, directors,
boards, shareholders, employees, agents and their heirs, administrators, executors, successors, and assigns from all
demands, actions, suits, proceedings, damages, claims and liabilities of any kind, whether known or unknown,
which arise from or are connected with my or the Minor’s participation in the event.

I am aware that in addition to typical activities such as Bible study, worship, sight-seeing, using public
transportation, and meal functions; that I or the Minor may participate in various other activities that may involve
some risks, such as service projects and recreational activities. I have read the informational materials about this
Event and the site and understand the risks involved in the planned activities. I recognize that the conditions,
equipment or standards in some of the places which I or the Minor will travel may not be of the same quality level
or standards as the conditions, equipment or standards to which I am accustomed. I realize further that there are
certain health risks as well as other risks to me or the Minor and our property. I enter into participation in this
Event with knowledge of those risks and acceptance of responsibility for any harm, injury or damage resulting
therefrom. If for any reason I am unable to complete my stay at the Event, I assume full responsibility for expenses
incurred for my return home.

In the event of an emergency, I hereby authorize a leader of this activity, as an agent for me or the Minor, to consent
to: any x-ray, examination; medical dental or surgical diagnosis; treatments; hospital care advised and supervised by
a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state or country where
services are rendered, either at a doctor’s office or in a hospital. I expect to be contacted or my family contacted as
soon as possible.

I understand that this document constitutes a full and complete waiver and release of any and all possible claims for
any act or omission, including claims for negligence regarding injury or property damages, arising out of my or the
Minor’s participation in the Event.

I understand that this release applies to, covers, and includes unknown, unforeseen, unanticipated, and
unsuspected risks, damages, losses, or liabilities and the consequences thereof, which result from the matters herein
before inferred to as well as those not disclosed and known to exist. The provisions of any state, federal, local or
territorial law or statue providing in substance that releases shall not extend to claims or damages which are
unknown or unsuspected to exist at the time are hereby expressly waived by me.

Furthermore, I do hereby expressly stipulate, and agree to indemnify and hold forever harmless the Southern
Wisconsin District, the Lutheran Church-Missouri Synod, Mount Calvary Lutheran Church, and their agents,
servants, successors, assigns, boards, directors, trustees, officers, employees, and other representatives against loss
from any and all present or future claims, demands or actions in law or in equity that may hereafter be made or
brought by me or the Minor or on our behalf, related to or resulting from any occurrence, act or omission during the
Event, or travel to and from the Event.

I also hereby release and waive any and all claims for liability against any of the host churches, host institutions and
the employees, agents, officers, directors, shareholders, contractors and assigns of such host church or host
institution or the owner of any sites that I or the Minor may be at during the Event.

By acceptance of participation in the Event, the undersigned agrees to the foregoing and also agrees that the
Southern Wisconsin District, the Lutheran Church-Missouri Synod, Mount Calvary Lutheran Church, and their
employees and other representatives, shall not be liable for loss, damage, injury or inconvenience caused by or
resulting from the malfunction of transportation, equipment, strikes, acts of war or insurrection, fire, delays, theft
or itinerary or schedule changes or cancellations.

I certify that I am of lawful age and competent to sign this Release, or that I have all right, power and authority to
do so on behalf of the Minor, that I understand its contents and that I have signed this release voluntarily.
Mount Calvary Lutheran Church, 2940 Mineral Point Avenue, Janesville, WI 53548
Phone (608) 754-4145

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