Music Camp Registration Music Camp 2023 "*" indicates required fields Youth Name* First Last Parents/Legal Guardians Grade Entering in the Fall*7 - 9:00 a.m. to 3:30 p.m.6 - 9:00 a.m. to 3:30 p.m.5 - 9:00 a.m. to 3:30 p.m.4 - 9:00 a.m. to 3:30 p.m.3 - 9:00 a.m. to 3:30 p.m.2 - 9:00 a.m. to 3:30 p.m.1 - 9:00 a.m. to 11:30 a.m.Kindergarten - 9:00 a.m. to 11:30 a.m.Birth Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneParent/Guardian Daytime Phone 1*Parent/Guardian Daytime Phone 2Parent/Guardian Email 1* Enter Email Confirm Email Parent/Guardian Email 2 Enter Email Confirm Email T-Shirt SizePlease indicate the size (XS, S, M, L, XL, etc.), including whether it is an adult or youth size. Health/Food ConcernsPlease list: allergies to food and drugs; medications your child is taking; activity restrictions and other important considerations.Physician's Name and Clinic Name Physician's PhoneHealth Insurance Co. Health Policy Number Emergency Contact Name and Phone Number* Who has legal custody of the youth and is legally able to make decisions on behalf of this youth? Please be specific.*Who has permission to pick up your child from Music Camp?*ConsentPerson completing this form.Please tell who is completing this form. Whoever is giving consent must be legally able to provide this consent. Parent/Guardian Consent (Or youth, if 18 or over)*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 agree. Δ
