Student’s Name: _________________________________________________________________________________

Date of Birth:___ /___ /___ Gender: M F Current Grade: _______________________________________

Insurance Provider: _______________________ School: ________________________________________________

Sanctuary Covenant Church
Student Ministry Event Slip

Policy #: ________________________________ Phone: ________________________________________________

Known Allergies: ________________________________________________________________________________

Current Medications: _____________________________________________________________________________

Current medical conditions/concerns: ________________________________________________________________

Parent Information & Home Address: Emergency Contact Information:

Parent’s Names: ___________________________ Please provide the information requested for a relative or friend
to contact if parent(s) are not available.
Home Address: ____________________________
Name: ____________________________________________
City/State: ________________________________
Relationship to Student: ______________________________
Zip: ___________ Phone: (___)______________
Daytime Phone: (___)_________________________________
Daytime Contact Name: _____________________
Evening Phone: (___) _________________________________
Daytime Contact Phone: _____________________

Event Information

Event Name: Sanctuary Covenant Lock-In

Event Location: YMCA 1711 West Broadway Avenue, Minneapolis, MN
Event Date: Friday, March 12th at 7:00 p.m. to Saturday March 13th at 9:00 a.m.

Medical/Liability Release

Parents! Please read the following statement and sign below.

I/We, the undersigned, are the parents having legal custody, or the legal guardians of the student named above, a minor, and have given our consent for him/her to attend
the event named above (hereinafter the “Event”) being organized by Sanctuary Covenant Church. This consent form gives permission for the above named student to
attend this Event, to seek whatever medical attention is deemed necessary, and releases Sanctuary Covenant Church and staff of any liability against personal losses of
your child. I/We understand that there are inherent risks involved in any event, and I/We hereby release Sanctuary Covenant Church, it’s employees, it’s agents, and
volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement with the
Event. In the event that he/she is injured while attending the Event and requires medical attention, I/We consent to any reasonable medical treatment as deemed necessary
by a licensed physician or medical facility. In the event treatment is required which a physician and/or hospital personnel refuses to administer without my/our consent,
I/We hereby authorize the Youth Ministry Staff Member in charge, or another adult leader designated by the Youth Ministry Department, to give consent for me/us, and
I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent so long as the treatment is
administered by or under the supervision of a licensed physician or medical facility. I/We also acknowledge that we will be ultimately responsible for the cost of any
medical care should the cost of that care not be reimbursed by the health insurance provider. Further, I/We affirm that the health insurance information provided above is
accurate at this date and will, to the best of my knowledge, still be in force for the student named above at the time of the Event. I/We also agree to bring my/our child
home should they become ill or if deemed necessary by the Youth Ministry Staff Member.

____________________________________________ ________________________________ Date Received:_____________

Signature Printed Name

____________________________________________ ________________________________ Staff Initials:_______________

For office use only

Relationship to Student Today’s Date

Payment Amount Received:

______________________