Adult LeaderLiability Form For St. Paul Lutheran Church

Name ____________________________________________________   Age ______  Date of Birth _____________________ 

Address/City/Zip _______________________________________________________________________________________

Home Phone #____________________     Cell Phone #___________________   Email_______________________________

Medical Information

Insurance Carrier _________________________________________        Policy Number______________________________

Insurance Carrier’s Phone _________________  Primary Doctor ____________________________Phone _______________ 

Date of Last Tetanus Shot ______________________   

Medical, emotional or mental issues we should know about  (ex: depression, diabetes, sleepwalking, etc)?

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Current Medications ________________________________________________________________________________________________

Release From Liability

I understand that participating in St. Paul Lutheran Churchactivities is a privilege.  Inconsideration of that privilege, I am signing this release of liability form onbehalf of myself who is participating in St. Paul Lutheran Church Youth Group(SPYouth) activities.

 I understand that bypartaking of SPYouth activities, I may participate in any number of activities,some of which include, but are not limited to, recreational activities, games,and service projects.  I understand thatthere are certain risks, whether such risks are known or unknown to me at thistime.  I further release St. PaulLutheran Church, including its directors, volunteers, employees, from any claimthat I may have against them as a result of physical injury or illness incurredduring participation in SPYouth activities. I hereby, for myself, my heirs, executor and administrators, waive andrelease any and all rights and claims for damages that I may have against theabove named organization and its agents, employees, representatives, successorsand assigns for any and all injuries suffered by myself that arise out of theabove-named program, activity or sport sponsored by St. Paul Lutheran Church.

_________________________________________                      _________________________________________________

Name (Printed)                                                                                              Signature                                                  Date

St.Paul Lutheran Church

Request for Criminal Records Check and Authorization

All volunteers workingwith children and youth at St. Paul are required  to submit a Request for Criminal Recordscheck.  This check must be completedbefore volunteering can begin.  Everyapplicant, regardless of criminal record, must complete this section.   Please also note that Michigan State requires“Ethnicity” when requesting a criminal records check.  I hereby request and authorize the release ofany information which pertains to any record of convictions contained in lawenforcement files or in any crime file maintained on me whether local, state,or national.  I hereby release local,state, and national law enforcement agencies from any and all liabilityresulting from such disclosure.

Have you everplead guilty, no-contest, or been convicted of a crime? If yes, give date andcircumstances:  ­­­­­­­­

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_______________________________________                     _________________________________
Print Full Legal Name                                                               PrintMaiden Name if Applicable

Print all aliases: __________________________________________________________________________ 

Gender:  Male    Female

Dateof Birth: ______________________________ Driver’s Licence#______________________________

Ethnicity:_________________________________________________

              (Ex: African American, EuropeanAmerican, Native American, Latino American, Middle-Eastern American, AsianAmerican, Multi-Ethnic, Hispanic, etc.)

Signature& Date: __________________________________________