Adult Permission and Medical Release Form

The Permission and Medical Release form only needs to be filled out once for each calendar year. The form below covers all LCC sponsored events and activities for the 2026 calendar year. If you have already filled this form out for a 2026 event or trip, you do not need to fill it out again. Please contact Andrew if you have any questions.

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Health insurance company name, phone number, and member ID or policy number:(Required)

Any allergies? If so, please describe:(Required)

Any medication being taken at this time? If so, please list and explain:(Required)

Any other medical conditions we should be aware of that may impact participation? If so, please explain:(Required)

Do you consent to be photographed or recorded in connection with youth activities, and release LCC, its staff, and its volunteers from liability in connection with such photographs or video footage.

Yes

Signature(Required)

I understand that typing my name below constitutes my legal electronic signature.

Name (Signature)(Required)

First Last

Name of Emergency Contact(Required)

First Last

Relationship to Emergency Contact(Required)

Phone Number of Emergency Contact(Required)

Email of Emergency Contact(Required)