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Medical and Release Form


    • Event Name *

    • Event Date(s) *

    • Participant's Name *


    • Parent/Gaurdian's Name *


    • Parent/Guardian Email *

    • Address *







    • Home Phone *

    • Cell Phone *

    • Permission

      I hereby give permission for my son/daughter to participate in the youth event named above on the dates specified. In consideration of permitting my son/daughter to participate in the described event, I hereby agree to indemnify and hold Saint Luke’s Parish, Darien, CT, its employees and agents harmless from any and all liability as a result of being injured while participating in said activity.

    • Medical Release

      In the event I cannot be reached during any medical emergency or following any accident occurring during any ministry event, I authorize Saint Luke’s staff or volunteer workers to act on my behalf in carrying out the best medical treatment possible in consultation with my child’s attending board certified physician or surgeon at an accredited clinic/hospital.
    • Insurance Company & Policy Number

    • Allergies or Medical Conditions

    • Medications

    • Last Tetanus Booster Shot

    • Physician's Name and Phone

    • Emergency Contact

      Parents, in the event that an emergency or discipline issue arises and we cannot contact you, please provide an alternate person who should be contacted.
    • Emergency Contact Name *


    • Emergency Contact Phone Number *

    • Emergency Contact Address







    • Emergency Contact Relationship to Youth

    • Parent's Initials Indicating Signature of Form *


Authentication Text*
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NOTE: Do Not Alter These Fields: