Parent Name

First Name

Last Name

Date *

MM

DD

YYYY

I understand Bethany Lutheran Church and School will make every effort to contact me, or those named, in case of an emergency requiring a physician. However, if unable to make contact, the Church leaders are hereby authorized to take whatever action deemed necessary in their judgment for the health of my child/children. I also understand the Church has no financial responsibility for emergency care for my child or transportation in an emergency vehicleshould the need arise. *

I agree with the statement above

I grant Bethany Lutheran Church and School permission to use photographs and/or videos of my child in publications (newsletters, weekly emails, worship bulletins, inserts, slideshows, etc.), including website entries. *

I give permission.

I do not give permission.