I give my child permission to attend Elementary Retreat at Camp Lutherwood. Transportation for this activity will be provided by an HSLC vehicle or other HSLC authorized adult driven vehicle. *

Yes

No

Child's Name *

First Name

Last Name

Parent Name

First Name

Last Name

Parent Phone Number

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

By submitting this form, I agree to the following

In the event it becomes necessary for Holy Spirit Lutheran Church staff or volunteers to obtain emergency care for my child, neither the staff, volunteers nor Holy Spirit Lutheran Church assumes financial liability for expenses incurred because of accident, injury, illness, and/or unforeseen circumstances.

As parent, or legal guardian, I authorize a qualified physician to examine the above-named child and in the event of injury to administer emergency care and to arrange for any consultation by a specialist, including a surgeon, as deemed necessary to insure proper care of any injury. I understand that every effort will be made to contact parent or guardian to explain the nature of the problem prior to any involved treatment.

I understand the itinerary and that Holy Spirit Lutheran church will make every reasonable effort to provide a safe environment during this special event. As the parent/guardian of the above named child, I understand that there are inherent risks associated with participation in these activities including physical injury, and/or other consequences. I acknowledge that “Covenant of Conduct” rules of behavior apply during all special events.