Permission Form For Minors - The Lutheran Church of the Holy Spirit

This form is intended for use by minors aged 17 and below. Please complete this form on-line and then press "Submit". The completed form will be emailed to you. Sign and submit the emailed form to the church office. Alternately, to manually print and complete this document, first click below to choose the desired "Purpose of Form Submission". Then

Purpose of Form Submission *
Annual Permission Form
CAT Camp
Minor's Full Name *
For minors aged 17 and below.
has my permission to attend any church activity, except out of town overnights, at The Lutheran Church of the Holy Spirit, Emmaus, PA valid through August 31, 2025. Out of town overnight events require a different individual permission form.
has my permission to participate in the Lutheran Church of The Holy Spirit’s CAT Camp from September 20, 21 and 23, 2024, which includes overnight stay at Bear Creek Camp in Wilkes Barre, PA. The registration fee for a youth is $50.00. You are welcome to contribute to the actual total cost of $200.00 per participant. You can make a check payable to Lutheran Church of The Holy Spirit and mark the memo line “CAT Camp 2024 and return this form and your payment to the church office.
As a parent I would like to volunteer at CAT Camp. All parents are required to attend at least one CAT Camp while their child is in Catechism.
I would like information about a scholarship for my youth.
My youth is unable to attend. Each youth is required to attend two CAT Camps before they affirm their Baptism. Any youth who is unable to attend CAT Camp is strongly encouraged to make up the missed work. A make-up assignment will be provided to youths not attnding the minimum number of times.
Household name
Gender *
Male
Female
Birth Date *
Full Address *
Minor's Email Address
Home Phone
Minor's Cell/Mobile Phone (if applicable)
Primary Parental Contact Name *
Secondary Parental Contact Name *
Insert “N/A” if not applicable.
Primary Parental Contact Cell Phone *
Secondary Parental Contact Cell Phone *
Insert “N/A” if not applicable.
Primary Parental Contact Work Phone
Secondary Parental Contact Work Phone
Step Parent
If applicable.
Others Authorized To PIck-up
Household Email Address *
School Grade *
School Name
Date of Baptism
Date of First Communion
Date of Confirmation
Christian Conduct
Just as Jesus did, I will treat other people and myself with respect and love. I will not, for any reason, hit or abuse anyone verbally or physically. I will not use any kind of illegal drugs, alcohol, or weapons, including but not limited to knives, firearms, or fireworks at the Lutheran Church of the Holy Spirit and church sponsored activities. The use of tobacco products is prohibited by minors and only permitted outside in designated areas by adults. Remember, even second hand smoke is harmful.
Electronic Devices
Cell phones will be permitted for emergency use only. If I or my child brings any electronic device, I release The Lutheran Church of the Holy Spirit, Emmaus, PA from any or all responsibility or damage of said electronic devices.
Photo Permission For Events (Check all for which you give permission.)
I give permission to the Lutheran Church of the Holy Spirit to display on church websites or in electronic publications of the church photos and video of my child until my child turns 18 or revoked by me in writing.
I give permission to the Lutheran Church of the Holy Spirit to display within the church facility any photo or video of my child until my child turns 18 or revoked by me in writing.
Checkboxes
I give permission to news media (usually local newspapers) to take photographs or film of an event at the church or church related event including my child, and publishing my child’s name, until my child turns 18 or revoked by me in writing.
In an emergency please contact:
Name *
Relationship *
Emergency Phone Nr. *
Insurance Information
Accident and sickness insurance is not provided by Lutheran Church of the Holy Spirit. Families are asked to use their family policy as primary carrier to satisfy all claims.
A copy of both sides of your medical insurance card is required for participation. If your insurance information changes, it is your responsibility to submit a new copy of your medical insurance card.
Complete all insurance information that applies.
Insured's Name *
Insurance Company *
Plan *
Group Number
ID/Member Number *
Medical Information
Does participant have any physical, emotional, or mental limitations, problems, or concerns that would be helpful if the staff was aware of or may affect the whole group, i.e. sleeping problems, destructive behavior? If yes, explain:
Known Allergies
Current Medication Name
Dosage, Quantity and Frequency, Directions, Reason for Medication
Attach additional sheet if necessary.
2nd Medication Name
Second Medication Dosage
Third Medication Name
Third Medication Dosage
Fourth Medication Name
Fourth Medication Dosage
I recognize that there may or may not be risks involved in participating in any activity. I hereby assume all risk of injury, harm, damage, or death to my minor child in connection with his/her participation in an activity at or through The Lutheran Church of the Holy Spirit.

To the fullest extent permitted by law, I release The Lutheran Church of the Holy Spirit, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur to my minor child while participating in the activity and agree to save and hold harmless The Lutheran Church of the Holy Spirit, its trustees, officers, directors, employees, agents, representatives from any claims arising out of my minor child’s participation in an activity. Further, being the parent or legal guardian of my minor child, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for my minor child. I understand that efforts will be made to contact me prior to treatment but, in the event I cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. As parent or legal guardian, I understand that I am responsible for the health care decisions of my minor child and agree that my insurance plan is the primary plan to pay for the medical, dental, or hospital care or treatment that is given to my minor child.

The taking of prescription medication is the responsibility of the individual taking the medication and/or that individual’s parent or guardian. A leader, after obtaining all the necessary information, may agree to accept responsibility to be sure a minor takes the necessary medication at the appropriate time, but LCHS does not mandate or encourage a leader to do so.
I have read and accept all of the provisions specified in this form.
Parent/Guardian Signature
(Sign the form emailed to you after you have completed the form itself.)
Minor Child Signature (6th grade and above)
Date
Comment

After you have completed this form and clicked "Submit", a completed form will be emailed to you. Please sign the completed form and return it to the church office. If any remittance is required, you can include a check addressed to The Lutheran Church of The Holy Spirit, or you can make any desired payment on-line by clicking below.