LUTHERAN CAMPFORMATION
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Welcome!
About Lutheran Campformation
Camp Pinerock
Additional Camp Pinerock Forms
Counselor Application
Camper Registration
Counselor Registration
Adult Leader Registration
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?
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Yes
No
If NO, would you be willing to transport other participants?
*
Yes
No
Please fill out the Adult Registration Form.
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?
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Yes
No
Insurance Provider
*
Policy Holder
*
Group Number
*
Please check any health conditions your child has.
*
Asthma
Heart Disease
Diabetes
Bleeding/Clotting Disorder
Musculoskeletal Disorder
Seizures
Fainting
Frequent Headaches
Depression/Anxiety
ADD/ADHD/Etc.
None
Please list any other current medical conditions or health concerns we should be aware of (if none, type NONE.)
*
Special Dietary Needs
*
Date of Last Tetanus Shot
*
Does you child have any activity restrictions?
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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
Home
Welcome!
About Lutheran Campformation
Camp Pinerock
Additional Camp Pinerock Forms
Counselor Application
Camper Registration
Counselor Registration
Adult Leader Registration