Registration CLOSED. Twin Cities Trip 2021
REGISTRATION CLOSED.
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Email *
Name of Participant *
Grade Completed 2020-2021 *
Required
Birthdate *
MM
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DD
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YYYY
Participants Phone Number
Address *
City, State, Zip *
Parent/Guardian *
Parent/Guardian Phone Number *
Parent/Guardian Secondary Phone Number
Insurance Company *
Insurance Policy Number *
Insurance Phone
Dietary restrictions *
Food Allergies/Comments
Drug Prescriptions/Allergies
Additional comments regarding medical history that may be needed in treatment or helpful for volunteers
Parent/Guardian (22+) is interested in being a leader on the "Twin Cities Trip 2021" if needed.
$25 Non-Refundable Deposit Due by June 15 (Mail to Hope Lutheran, PO Box 506, Walker) *
Required
I understand that the full payment is due before departure on June 27, 2021 *
PARENTAL AUTHORIZATION- MUSTBE SIGNED BY PARENT/GUARDIAN IF CHILD IS UNDER THE AGE OF 18! My child has permission to take part in all "Twin Cities Trip 2021" activities under supervision and I agree that Hope, or its personnel, will not be held responsible for accidents or personal injury arising therefrom. Hope Lutheran has my permission to use photos of my child for promotional purpose. In the case of a medical emergency, I understand that every effort will be made to contact the parents or guardians. In the event I cannot be reached I herby give permission to the medical examiner selected by the Church staff to hospitalize, to secure proper treatment for, to order an injection, anesthesia, or surgery for my child as named on this form. I understand that Hope Lutheran does not provide medical insurance. I agree to pick up my child upon notice due to disruptive behavior and will pay for any damages caused by my child. In this period of Covid19, I will not send my child if they are feeling ill and I will abide by the policies in place to protect other youth, staff & volunteers from the sickness.   *
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