2022-2023 Lakewood Student Ministries Registration

Student Information

Student Name

Birth Date

Age on 9/1/22

Gender

Male Female

Student Cell

May We Send Texts?

Student E-mail

Is Student on Facebook?

Address

Parent Information

Primary Parent/Guardian Name

E-mail

This address will receive a confirmation email

Home Phone

Cell Phone

Cell Phone Provider

May We Send Texts?

Are You on Facebook?

Secondary Parent/Guardian Name

Secondary Parent Cell Phone

Secondary Parent E-mail

Secondary Parent Address

Emergency Contact (Other Than Parent)

Relationship

Emergency Contact Phone

Health Insurance Information

Insurance Company

Policy Holder's Name

Group #/ PolicyType

Policy #

Group/Policy Phone Number

Please list any medical information and allergies we need to know about. Please include current medication and condition for which it is needed. Please describe in detail any physical/or psychological condition to which your student is subject and of which the staff should be aware of and what, if any, action of protection is required.

Transportation Release

I give permission to lakewood employees and volunteers to take my student to and from events as part of activities and to necessary facilities in case of emergency. I understand that my student will be transported in a vehicle owned by Lakewood or an employee or LSM Leader's personal vehicle. Electronic Signature:

Date Signed

Disciplinary Policy

In the event of a sever disciplinary problem, it is understood that LSM will have the authority to resolve the problem. In extreme or unresolvable cases, parents will be notified and the student will be sent home at the parents' expense. Electronic Signature:

Date Signed

Media Release

I understand/authorize that my student's image may be photographed /filmed and used in Lakewood video presentations, printed publications, the church website and/or Facebook. Electronic Signature:

Date Signed

Parent Approval Liability Waiver/Release

I/we, the parent(s), on behalf of the below named student for whom I am legally responsible, accept the conditions and risks outlined in this waiver and release and consent to his or her participation in the activities that are sponsored by Lakewood Evangelical Free Church of Baxter, Minnesota (the “Church”). These activities include, but are not limited to: Refuel events, summer events, beach days, small group outings, service projects, BAY Rallies, retreats, mission trips, camping and other programming. I represent and agree that:

Please Read above Release and answer Yes or No for each section below. Please sign and date to approve.

Section 1

Yes No

Section 2

Yes No

Section 3

Yes No

Section 4

Yes No

Section 5

Yes No

Section 6

Yes No

Section 7

Yes No

I/We have executed this waiver and release on the date listed below and I/We understand this release will apply to the activities taking place from August 2022 Through August 2023/ Parent Signature.

Date Signed

2022-2023 Lakewood Student Ministries Registration

Description

Please Fix the Following