Calvary Lutheran Church

Youth 1 Name *

First Name

Last Name

Youth 1 DOB *

MM

DD

YYYY

Youth 1 Gender *

Male

Female

Youth 2 Name

If registering second youth.

First Name

Last Name

Youth 2 DOB

MM

DD

YYYY

Youth 2 Gender

Male

Female

Youth 3 Name

If registering third youth.

First Name

Last Name

Youth 3 DOB

MM

DD

YYYY

Youth 3 Gender

Male

Female

Parent/Legal Guardian Name *

First Name

Last Name

Preferred Phone During CIS *

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

At least one Emergency Contact is required

First Name

Last Name

Emergency Contact Phone *

(###)

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Emergency Contact 2

Not Required

First Name

Last Name

Emergency Contact 2 Phone

(###)

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Physician Name *

First Name

Last Name

Physician Phone *

(###)

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Subscriber Name *

First Name

Last Name

Participation Permission and Liability Release Agreement *

I/We give my permission for the participant(s) named above to participate in Teen Leadership & Service at Calvary Lutheran Church in West Chester, Pennsylvania for the week of July 8-12, 2024. I release Calvary Lutheran Church from any and all liability to me or my child(ren) as a result of his/her participation. Also, I understand that Calvary Lutheran Church does not assume any responsibility for loss of, or damage to, personal property of the participant.

I/We agree.

Medical Treatment Consent and Release *

I/We do hereby consent to any hospital, medical, or surgical care and treatment and the administration of anesthesia, determined by a qualified physician to be necessary for the welfare of my child(ren) while my child(ren) is under the care and custody of an adult leader of any activity sponsored by Calvary Lutheran Church of West Chester, Pennsylvania, in the event I can not reasonably be contacted for consent. I understand that I am responsible for and agree to pay all costs and expenses incurred in connection with such medical and/or dental services rendered to my child pursuant to this authorization.

I/We agree.

Image Release Agreement *

I/We grant Calvary Lutheran Church permission to use my child(ren)'s likeness, without names, as recorded while participating in activities sponsored by Calvary Lutheran Church of West Chester, Pennsylvania, in photographs, video recordings or electronic images, in any and all of its publications, including website and social media entries, without payment or any other consideration.

I/We agree.

Sponsorship

Help make Teen Leadership & Service Camp possible for another child. Simply add the number of sponsorships to your registration number and indicate "Sponsorship" using the payment method you choose.

I'd like to sponsor another child(ren).