This consent and release will remain in effect from November 1, 2025 through November 1, 2026.

Sponsoring Organization:
LifeSpring Church, SBC
13904 S. 36th Street
Bellevue, NE 68123
402.292.4546

Lead Pastor: Derrick Nichols
Student Ministry Coordinator: Mark FitzHenry Jr.
Children's Minister: Leah Kossakoski

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Fields with an * are required.

Child/Student Information

Child/Student Name * Child/Student Date of Birth *

Additional child(ren) / Student(s) Included Under This Agreement:

2nd Child or Student Name & Date of Birth 3rd Child or Student Name & Date of Birth 4th Child or Student Name & Date of Birth

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Parent / Guardian Information

First & Last Name * Phone Number * Email Address* Secondary Parent/Guardian Name & Phone Number Emergency Contact (Other than one listed above) Name & Phone Number * Insurance Company * Policy Number *

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Permissions & Agreement

The undersigned gives permission for their child(ten)/student(s) to attend and participate in any and all Student Ministry events from November 1, 2025 to November 1, 2026. Transportation Permission * The undersigned hereby gives permission for their child(ren)/student(s) to ride with an adult over the age of 25 in personal vehicles, church-owned vehicles, or rented vehicles. YesNo
Medical Authorization & Liability Release * I agree to the medical authorization and liability release terms below
We (I) authorize an adult, in whose care my child(ren)/student(s) has been entrusted, to consent to any emergency medical treatment to be rendered to my student(s) under the supervision and advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital and/or emergency medical care facility. We (I) do herewith authorize the treatment by this authority, and it is granted only after a reasonable effort has been made to reach us (me), the parent(s) and/or guardian(s). Our (my) signature(s) serves to indicate our (my) willingness to take full financial responsibility for any and all medical services rendered for my child(ren)/student(s). We (I) release LifeSpring Church from this liability.

The undersigned does hereby release and agree to hold harmless LifeSpring Church and their directors, employees, agents, or representatives from any and all liabilities and claims for personal injury, illness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by my child(ren)/student(s) that may occur while said child(ren)/student(s) is/are participating in the trip.

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Digital Signature

Parent/Guardian Name (Typed Signature) * Today's Date *
By submitting this form, I certify that I am the parent/legal guardian of the child(ren)/student(s) listed above and that I agree to the terms and permissions outlined in this form. Yes, I understand