Lamont Wesleyan Church - Student Travel Form

Student First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Birthdate

Grade

Shirt Size

By attaching my name and email to the bottom of this form, I attest that I am the legal guardian of the named student and I hereby give my permission for this student to participate in the Youth Ministries. This includes regularly scheduled events, or any special events (including travel) that are sponsored by the Lamont Wesleyan Church Youth Ministries. January 1, 2025 - December 31, 2025. Should any problems arise concerning the behavior of my student that would require them to return home prior to the end of any church activity, I will pay for his or her return or come pick my student up. I further give permission to administer first aid, and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be borne by the parents or guardians of the participant. RELEASE OF LIABILITY I/We, the parent(s) or legal guardian(s) of the above participant do hereby release Lamont Wesleyan Church, the Church staff, all sponsors, and volunteers from any and all liability resulting from any physical injury, property damage, or other injury or damage which occurs in connection with Youth Events. Attach below: Parent(s)/Legal Guardian(s) Name, Address, Phone #, and email.

Medications

Non Prescription Medication

Allergies

PERMISSION TO USE STUDENTS IMAGE: I recognize Lamont Wesleyan Church uses photographs and videos of images from events in our publicity materials such as church website and social media. I hereby grant permission for photo/video images of my child to be taken and used for such purposes.

Yes

No

HEALTH INSURANCE INFORMATION: Insurance Company

Insurance Subscriber

Subscriber Birthdate

Policy ID #

Group #

Primary Doctor & Doctor Phone #

In the event of an emergency, we will attempt to reach a legal guardian. If we are unable to do so, please list he name relationship to the student, and phone number for an additional emergency contact:

Parent(s)/Guardian(s) signature and date: