Purpose of Form Submission * Adult's Full Name * Birth Date * Full Address * Home Phone Cell Phone * Spouse's Cell Phone Email Address * 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.
I will not bring a DVD player, iPOD or tablet PC. I understand I am expected to limit cell phone use to emergencies and unstructured time. If I bring an electronic device, I release the Lutheran Church of The Holy Spirit, Emmaus PA from any or all liability or damage of said electronic devices.
Photo Permission For Events (Check all for which you give permission.) 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.
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. A copy of both sides of your medical insurance card is required for participation. 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 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 myself in connection with my 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 me 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 participation in an activity.
Further, I do consent to any medical, surgical, x-ray, anesthetic, or dental treatment that may be deemed necessary for me. I understand that efforts will be made to contact my emergency contact prior to treatment but, in the event he/she cannot be reached in an emergency, I give permission to the activity leader to make the decisions necessary for treatment. I understand that I am responsible for my health care decisions 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 me. The taking of prescription medication is my responsibility.