First and Last Name of person completing registration form *
Email Address for confirmation of registration *
Street address *
City, state, zip *
Home phone *
Youth Information
Youth 1 Name *
Youth 1 Birthdate *
Youth 1 Grade as of fall 2013 *
Youth 1 Gender *
Youth 1 Special needs/allergies/health concerns:
Youth 1 Registering for: *
Youth 2 Name
Youth 2 Birthdate
Youth 2 Grade as of fall 2013
Youth 2 Gender
Youth 2 Special needs/allergies/health concerns:
Youth 2 Registering for:
Youth 3 Name
Youth 3 Birthdate
Youth 3 Grade as of fall 2013
Youth 3 Gender
Youth 3 Special needs/allergies/health concerns:
Youth 3 Registering for:
Would you like one-on-one assistance for your child(ren) from a Special Needs Buddy?
Parent/Guardian Information
Parent/Guardian 1 name *
Parent/Guardian 1 cell phone *
Parent/Guardian 1 email *
Parent/Guardian 2 name
ParentGuardian 2 cell phone
Parent/Guardian 2 email
Parent chaperones are needed. Would you be interested in serving for this event?
Please indicate the date(s) you are able to help. Thanks!
If you are not currently a member of Lord of Life would you like to receive membership information?
Permission Section
Release from liability: Guardians hereby authorize my son/daughter to participate in said activity. Guardians hereby release, forever discharge and agree to hold harmless, Lord of Life Lutheran Church, from the described event, and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the described event. The undersigned further hereby agrees to hold harmless and indemnify Lord of Life Lutheran Church, its directors, employees and agents for liability sustained by said acts of said participant, including any expenses incurred. The undersigned also gives permission for photos to be used online and in print. *
Medical release: The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify Lord of Life Lutheran Church, its directors, employees and agents from any acts of misconduct, and/or failure to act on the part of those chosen to administer medical aid on behalf of the participant. *
Registration is not complete without payment. You will be brought to the e-pay page when you click submit. Please select the correct event date and quantity, for number of students you are registering, when placing items in your cart. Scholarships are available. Please contact Pastor Todd at todd@lordoflife.org .
