Day of Service Registration

LUTHERAN CAMPFORMATION

Student Information

Parent/Guardian Information

* Indicates required field

Student's Name *

First

Last

Parent/Guardian Name *

First

Last

Student's Date of Birth *

Gender (Student Identifies as) *

Parent /Guardian Email Address *

Parent/Guardian Phone Number *

Student Phone Number *

Parent/Guardian Name *

First

Last

Student's Email Address *

Parent/Guardian Phone Number *

Student's Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Congregation *

Parent/Guardian Email *

Region where you are participating in Day of Service Event *

Las Vegas Phoenix Metro: North Phoenix Metro: East Tri-Cities

TRANSPORTATION

Will your participant need transportation? *

Yes No

If NO, would you be willing to transport other participants? *

Yes No

Do you have automobile insurance? *

Yes No N/A

Are you 26 years of age or older? *

Yes No N/A

Number of extra working seatbelts available? Please reply N/A if not able to transport other participants. *

HEALTH AND MEDICAL INFORMATION

Student's Health Care Provider *

Health Care Provider Phone *

Do you have Health Insurance? *

Yes No

Insurance Provider *

Policy Holder *

Group Number *

Special Dietary Needs *

Date of Last Tetanus Shot *

Does you child have any activity restrictions? *

Yes No

If yes, what activity restrictions? *

ALLERGIES

List any known allergies with the reaction (food, medications, etc) *

PHOTO RELEASE STATEMENT
Lutheran Campformation takes photos and videos with the intent to celebrate the mission of Lutheran Campformation. These pictures and videos MAY be used in social media and website promotion, but will not include any information on the individuals pictured (names, church affiliation, etc.). By submitting this form, you acknowledge this photo release statement and agree.
(Any concerns with the photo release statement can be brought to the attention of your church representative.)

MEDICAL AND LIABILITY RELEASE STATEMENT
Lutheran Campformation Adult Leadership to provide routine health care and emergency first aid; to release any records necessary for treatment or insurance purposes, and to provide or arrange necessary transportation. I understand that my insurance information will be given to any healthcare providers, but that I will ultimately be responsible for any medical charges in the case of illness or injury while my youth is participating at Lutheran Campformation or a related event. In the event I cannot be reached in an emergency, I hereby give the permission to the physician selected by the Lutheran Campformation Leadership to secure and administer treatment, including hospitalization, for the person named above.

I understand that participation in this event is not without risk to my child because of the group nature of the event and the unpredictable behavior of any group, even when managed with the greatest amount of care. I understand that all reasonable safety precautions will be taken at all times by Lutheran Campformation. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to not hold Lutheran Campformation, its leaders, employees, volunteers or your home church liable for damages, losses, diseases, negligence, or injuries, or death incurred by my youth.

AGREEMENT - ELECTRONIC SIGNATURE

By checking YES below, you are confirming your agreement to the terms outlined above and that the information provided is complete and accurate. *

Yes

Parent/Guardian, please type your full first and last name. This serves as an electronic signature confirming your agreement to the terms outlined above and that the information provided is complete and accurate. *

If you are able to transport other participants and will be staying for the service events, please fill out the Day of Service - Adult Registration Form.

Thank you!

Submit