___________ Middle/Jr. High School

(515)555-1234

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I give permission for my child(ren)’s photograph (still or video), artwork, written work, voice, verbal statement or portrait to appear in St. Mark’s printed and/or electronic publications (including but not limited to brochures, website, Facebook, videos) and in third-party media outlets (including but not limited to newspapers, magazines, websites) for the purposes of public relations, public information, church promotion, publicity, and instruction. Such publications may or may not personally identify your child. The Parent/Guardian further understands and agrees that no monetary consideration shall be paid; that consent and release have been given without coercion or duress; that the aforementioned media may be used in subsequent years and that this agreement is binding upon heirs and/or future legal representatives. I also hereby release St. Mark and its staff and/or agents from all claims, demands, and liabilities whatsoever in connection with the above.

I give permission for my child(ren) to take part in all St. Mark Lutheran Church Children’s Ministry events and activities. I hereby release, discharge and indemnify St. Mark and its staff from responsibility and liability for any injury or illness that my child may sustain during these activities. In an event of an emergency, I hereby authorize the adult supervisor of this activity as agent for me to consent to any medical, dental, surgical, treatment and care deemed necessary by a licensed medical or dental professional. I consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician, dentist and/or surgeon licensed under the Medical Practice Act and Dental Practice Act for my child. I expect to be notified as soon as possible. I agree to keep current contact information on file with St. Mark. I further agree to assume the financial responsibility for the medical, dental or hospital care or treatment.

By typing my name below I am signing this agreement electronically.  I agree my electronic signature is the legal equivalent of my manual signature.  My typed name below is my consent to be legally bound to my selections of the Media Release and Events Permission and Medical Release.