LK Summer Impact 2022 Student Registration

Student Information

Student Name

Age as of June 1, 2022

Grade completing this year

Parent Information

Primary Parent/Guardian Name

E-mail

This address will receive a confirmation email

Home Phone

Cell Phone

May We Send Texts?

Summer Impact Dates and events- select each date participating

Prayer Path/Escape Room June 23

40 Winks Quilt design/Neighborhood Scavenger Hunt June 30

Be a Pal( pen pal letter writing to the elderly)/Painting with the Devine's July 7

Operation Sandwich/ Movie Matinee July 21

Butterfly Saucers for Arboretum/ Outdoor Carnival July 28

Care Bags for Chaplaincy/Pirate's Cove August 4

Health Insurance Information

Insurance Company

Policy Holder's Name

Group #/ PolicyType

Policy #

Group/Policy Phone Number

Prefered Hospital or Clinic

Please list any allergies to food or medication? please list the reactions and any medications that are used to treat the allergic reaction.

Medical Release

I hereby authorize the Lakewood Kids Ministry Staff to secure medical treatment for myself/my child/my family members if necessary. Electronic Signature:

Date Signed

Transportation Release

I authorize my child to be transported by Bus, or other Lakewood transportation to any off campus planned activity. 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 have chosen to allow myself/my child/my family members to participate in Lakewood kids Summer Impact events and activities. I understand and acknowledge that participation in the everyday service and fun activities offered entails risks both known and unknown, regardless of negligence which could result in serious physical or emotional injury, paralysis, and or death, or damage to the participant, to property, or to third parties beyond the control of Lakewood Church. I hereby release and discharge, indeminify nad hold harmless to the fullest extent permitted by law, Lakewood Church, its Pastors, directors, employees, agents, volunteers and assigns from any and all liability, claims, demands, costs and expenses, and causes of action whatsoever arising out of or in any way connected with any property loss and /or bodily injury including death and/or disability arising from myself/mychild/myfamily members' participation in Lakewood Kids Ministry activities. Electronic Signature:

Date Signed

From the drop down - select the number of Summer Impact events you are registering this student for:

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

LK Summer Impact 2022 Student Registration

Description

Please Fix the Following