Find Us On Facebook
16790 Van Wagoner St
Spring Lake, MI 49456
(616) 846-8556
Service Times
Sundays 9 and 10:45am
Generated with MOOJ Proforms
* Required information.

LAKESHORE FELLOWSHIP - PARENTAL CONSENT FORM 

Parent/Guardian must read and complete this entire form. In the event of an emergency, this form will be essential for parental contact and appropriate care. This form will remain in effect from September 1 until August 31 of the following year for the school calendar year indicated above.

Student Information
Student’s First Name: *
Student's Last Name: *
Gender: *
Date of Birth: *
Age: *
School: *
Year of Graduation *
Contact Information
Street Address: *
City: *
State: *
Zipcode: *
Home Phone: *
Cell Phone: *
Emergency Information
Name(s) of Legal Parent/Guardian: *
Address, if different:
Emergency Phone: *
Specific medical allergies, chronic illness or other conditions:
Primary Insurance Information
Primary Health Insurance Company: *
Subscriber’s Name: *
Policy #: *
Date of Birth: * 1000
Secondary Insurance Information
Secondary Health Insurance Company:
Subscriber’s Name:
Policy #:
Date of Birth:
General Release / Hold Harmless Agreement

The undersigned or a member of the immediate family of the undersigned further understands and acknowledges that the undersigned or a member of the immediate family of the undersigned may incur personal injury or bodily damage while participating in such activity.

The undersigned or a member of the immediate family of the undersigned further understands and acknowledges that Lakeshore Fellowship would not allow the undersigned or a member of the immediate family of the undersigned to participate in such activity without releasing and holding harmless Lakeshore Fellowship.

Further, the undersigned or a member of the immediate family of the undersigned requests that Lakeshore Fellowship allow them to participate in any and all Lakeshore Fellowship activities and in consideration thereof agree to hereby release, and forever discharge Lakeshore Fellowship, their officers, their directors, employees, and any party volunteering on behalf of Lakeshore Fellowship from all actions, claims, damages, cost, expenses or damages of any kind growing out of or related to any activity of Lakeshore Fellowship in which the undersigned or a member of the immediate family of the undersigned participates, including transportation to and/or from such event.

The undersigned or a member of the immediate family of the undersigned further acknowledges that this is a full and complete release of the undersigned’s or a member of the immediate family of the undersigned’s participation in the Lakeshore Fellowship program.

The undersigned, being a parent and/or guardian of the above minor, does hereby authorize the treatment of the above minor by a qualified and licensed medical doctor in the event of a medical emergency, which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, while said minor is participating in any and all of Lakeshore Fellowship’s activities, including transportation to and from the event site.  This authority is granted only after a reasonable attempt has been made to contact me.

By checking this box you are confirming that you are the legal guardian of the minor listed above and it means you consent to the terms identified in the form. *
I Agree

Scroll Up