Student's Grade in School:*
If your student is in 7th grade, did they complete 6th grade Confirmation at Mount Olive?
Student's First Name:*
Student's Middle Name:*
Student's Last Name:*
Student's Date of Birth*
Student's Cell Phone Number:
Student's E-mail Address:
Student's Street Address:*
Student's City, State & Zip:*
Student's Home Church:
Is Student Baptized?*
If Baptized, Please Enter Date:
Name of Student's School:*
Name of One Friend You Would Like to be in your Group:
Mother's Full Name:
Mother's City, State & Zip:
Mother's Cell Phone Number:*
Mother's E-mail Address:
Father's Full Name:
Father's City, State & Zip:
Father's Cell Phone Number:*
Father's E-mail Address:
I am interested in being a guide huddle leader this year!*
Name of Person to be reached in case of emergency and parent(s) can not be reached (multiple names may be entered):*
Cell Phone Number of Person to be reached in case of emergency and parent(s) can not be reached (multiple numbers may be entered):*
Please list all medications and medical concerns - If not-applicable, enter 'none':*
Does the student have any learning concerns or an IEP that we should be aware of?
Family Doctor's Name:*
Family Doctor's Phone Number:*
Family Dentist's Name:*
Family Dentist's Phone Number:*
Name of Medical Insurance Company:*
Medical Insurance Policy #:*
Medical Insurance Company Phone Number:*
Medical and Dental Care Statement: understand that I have a duty to provide primary accident and medical insurance for my child and I declare that primary accident and medical insurance cover my child. I assume all responsibility and liability for injury to my child. I release and forever discharge The Lutheran Church - Missouri Synod, Mount Olive Lutheran Church, and their agents and servants, counselors, successors and assigns, directors, trustees, officers, employees and other representatives from any and all damages and causes of action either at law or in equity which I may have as a result of my child's participation in, attendance at, and travel to and from this youth activity. Furthermore, I do hereby expressly stipulate and agree to indemnify and hold forever harmless the Youth Committee, The Lutheran Church - Missouri Synod, and Mount Olive Lutheran Church, their agents and servants, counselors, successors and assigns, directors, trustees, officers, employees and their representatives agains loss from any and all present or future claims, demands or actions in law or in equity that may hereby be made or brought by my child, during the activity and following activities, or travel to and from the same. Finally, I give the adult in whose care the minor has been entrusted authority to act on my behalf in the event I am not able to be reached by phone number below and my child requires any medical attention.
I authorize the adults in whose care my minor child has been entrusted to see medical help for my child in case of an emergency. I also agree to allow my child to ride in a vehicle designated by the adults in whose care my minor child has been entrusted while attending this class/activity/trip sponsored by Mount Olive Lutheran Church.
I also grant permission to Mount Olive Lutheran Church to use any photos that may be taken of my child during this activity for church purposes such as website, publicity, etc.
I have read the Medical and Dental Care Statement in it's entirety and agree with all statements included there within.*
Name of Parent/Guardian that has read and agreed with the Medical and Dental Care Statement:*