Middle School Fall Retreat Registration

    I authorize that my child is granted full permission to participate in the events and activities organized by the Student Ministries of Lake Community Church.
    I understand that possible risks and dangers may be encountered on any given trip or event, and I the parent, trust the judgment of Lake Community Church, its pastors and staff, and volunteer leaders.  In the event of an emergency or injury to my child, I grant permission to Pastor Paul Peterson or a volunteer leader to seek appropriate medical attention for the injury to my child including visits to the emergency room or a doctor, X-Ray examinations, anesthetic and/or other medical/dental needs.  In the event of an emergency or injury, the church representative, staff or volunteer will first attempt to contact and consult with the parents and/or emergency contact person provided on this form, and will only continue to seek medical attention without parental consultation if the parent or emergency contact cannot be reached and if the situation is deemed necessary or extremely urgent.
    Understanding the above notice, I release Lake Community Church, its pastors and staff, volunteer leaders, and any event staff/volunteers of Trout Lake Camp from any and all liability claims for sickness, expenses, damages, medical services and injury, even injury resulting in death.

Event Name:  Middle School Fall Retreat

Effective Date:  October 10-12, 2014

Location:  Trout Lake Camp, Pine River, MN

Student Information *
Student Information
Address *
Address
Date of Birth *
Date of Birth
Student Cell #
Student Cell #
Primary Parent Contact *
Primary Parent Contact
Primary Parent Cell Phone *
Primary Parent Cell Phone
Additional Parent Contact
Additional Parent Contact
Additional Parent Cell Phone
Additional Parent Cell Phone
Emergency Contact Person (other than parents) *
Emergency Contact Person (other than parents)
Phone *
Phone
Insurance Provider
I certify that I am the parent or guardian registering the above listed student *