2022-2023 Grace Bismarck Student Information and Release Form

Please fill out the information below using your child's information (i.e. Your Name: (Child's Name)).

Your name *

Email address *

Birthday *

Gender *

Address *

Parent/Guardian Information

First and Last Name *

Phone Number *

Permission to Participate and Release of Information

I grant permission for my child to participate in all activities and events carried out by Grace Lutheran Brethren Church.

I grant permission for my child to be photographed to be used on Grace Lutheran Brethren’s website/social media.

I grant permission for my child to be photographed/recorded for a slideshow, video or picture board displaying events. Only to be used at Grace Church functions.

Emergency Care Authorization and Child Release Form

The undersigned, who are the parents or guardians having legal custody of the above-named minor, hereby authorize Grace Lutheran Brethren Church as caregiver of the below-named minor into whose care the below-named minor has been entrusted, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medical Practice Act, or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to said minor by a dentist under the provisions of the Dental Practice Act. The undersigned further authorize Grace Church to have the above-named minor released into the custody of its representative, should hospital care no longer be required. This form is to be used in an extreme EMERGENCY, when said parents or guardians or individuals authorized by the parents or legal guardians cannot be or are unavailable to be contacted.

Authorization of Medical Care/Emergency Care for: (student's name) *

By typing my name below, I agree to the terms of the "Emergency Care Authorization and Child Release Form." *

Parent/Legal Guardian Signature *

Date *

Medical Note

Please list any medical conditions or any food, medication, animal/environmental allergies. Describe reactions, protocol, and restrictions.

Emergency Contact #1 *

Please list the names and numbers of individuals who can assume medical/emergency responsibility IF THE PARENTS OR LEGAL GUARDIANS CANNOT BE REACHED.

Emergency Contact #1 Phone Number *

Emergency Contact #2 *

Please list the names and numbers of individuals who can assume medical/emergency responsibility IF THE PARENTS OR LEGAL GUARDIANS CANNOT BE REACHED.

Emergency Contact #2 Phone Number *

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