2020-2021 Discipleship Training Registration DISCIPLESHIP TRAINING REGISTRATION FORM 2020-2021 STUDENT INFORMATIONStudent Name* First Last Preferred Name Date of Birth MM slash DD slash YYYY Age Grade GenderMaleFemalePrefer not to sayAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Baptism Date MM slash DD slash YYYY Baptism Location First Communion Date MM slash DD slash YYYY First Communion Location CONTACT INFORMATIONStudent Email Student Cell Phone Texting available Texting not available Parent/Guardian 1 First Last Relationship to Student Parent/Guardian 1 - Email Parent/Guardian 1 - Phone Texting available Texting not available Parent/Guardian 2 First Last Relationship to Student Parent/Guardian 2 - Email Parent/Guardian 2 - Phone Texting available Texting not available Student Lives With:Both ParentsGuardiansMother OnlyFather OnlyFoster ParentsMother & StepparentFather & StepparentOtherEmergency ContactName of someone that can be contacted in an emergency, should one of the people listed above not be available. First Last Emergency Contact's relationship with student Emergency Contact's PhoneWho has permission to pick your child up from events/activities?EMERGENCY INFORMATIONAllergiesPlease list any allergies (food or other):Medical ConcernsPlease list any medical concerns that could affect the student while participating in events with the group:Learning ConditionsPlease list any conditions that could affect the student while participating in events with the group:Off Site PermissionBy clicking below I give my child permission to go off site to Les Paul Middle School or Cutler Park as staff chooses. I understand adult supervision will be provided. I agree and acceptConsent*In checking the "consent" box, I agree to the following: 1. I am legally able to consent for the above named youth to participate in this event. 2. I consent to my youth, as named above, to participate in this event. I understand that participation in this activity carries risks such as accidental injury and/or death. 3. I hereby fully release and discharge all claims that I may have for injuries or damages to me, against St. Luke’s Lutheran Church and other participating congregations, its officers, agents, servants, employees, pastor and affiliates as a result of participating in this activity. 4. I grant permission for leaders and participants of this trip to take photographs of me in connection with this activity and to use and/or publishing of the same in print and/or electronically. I agree that such photographs of me, with or without names may be used for any lawful purpose, including such purposes as publicity, illustration, promotion, and web content, including social media. – unless notice to the contrary is given in written form with this document. 5. I authorize leaders and chaperons traveling with and/or leading this event to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician or surgeon licensed to practice medicine by the state or country in which they practice, during this activity. I understand and agreeRelease through May 2021*Consent and release from Liability: St. Luke’s Lutheran Church for activities through May 2021 The child listed above has my permission to participate in all activities of St. Luke’s Lutheran Church, Waukesha, WI, through May 31, 2021 and to be transported by church vehicles or private car when necessary. I understand all events will have adult supervision. I further agree to direct my son/daughter to conform to the fullest with the directions and instructions of the leaders in charge of an event in which my child is participating. This consent and release is in effect until May 31, 2021, or until I give St. Luke’s Lutheran Church written notice to the contrary. I hereby fully release and discharge all claims that I may have for injuries or damages to my child or me, against St. Luke’s Lutheran Church, its officers, agents, servants, employees, pastor and affiliates as a result of participating in church-sponsored activities or using the facilities or equipment. This release includes granting permission to take photographs of my child(ren), my family, and me in connection with church-sponsored activities, and the use and publishing of the same in print and/or electronically. I agree that such photographs of my child(ren), my family and me, with or without names may be used for any lawful purpose, including such purposes as publicity, illustration, promotion, and web content, including social media – unless notice to the contrary is given in written form sent to the church office by mail or by email (office@stlukeslutheran.org). I hereby give permission and authorization for medical treatment for my child listed above, or me, including but not limited to emergency surgery, and assume the responsibility of all medical bills, if any. I understand that, subject to the participant’s interests and medical condition, attempts will be made to alert the parent/legal guardian before any such necessary medical treatment is given. I understand and agreeINSURANCE INFORMATIONPlease fill out this section if your student will be participating in any overnight activities.Health Insurance Company: Subscriber's Name: Policy Number: Insurance Company's Phone:
