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Pledge 2013
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Jr. High Mission Trip 201
3
Registration
*
Required
Name of person completing registration
*
Email address for confirmation of registration
*
Student name
*
Street address
*
City, state, zip
*
Home phone
Gender
*
male
female
Current grade
*
Date of birth
*
Parent/Guardian #1 name
*
Parent/Guardian #1 cell phone
Parent/Guardian #2 name
Parent/Guardian #2 cell phone
Medical insurance company
*
Insurance policy number (please send in a copy of your medical insurance card)
*
Current medication and/or important medical information we should be aware of
*
T-shirt size (these are adult sizes)
*
S
M
L
XL
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.
*
Agree
Disagree
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.
*
Agree
Disagree
For parent/guardian:
I also understand that if my child is intentionally creating problems or is found in possession of controlled substances, I may be contacted to provide immediate transportation home at our family's expense.
*
Agree
Disagree
For student:
I understand that I am to be a full participant in the 2013 Jr. High Mission Trip from the time we load the bus to the time we return. I will abide by the Lord of Life Youth Covenant and know that my actions can reflect either positively or negatively on myself, my church and my faith. I understand that if I cannot live by these expectations, I may be asked to contact my parents/guardians to arrange immediate transportation home at our family's expense.
*
Agree
Disagree
