Elementary Retreat Off-Site Permission Form

Register by signing up below, and placing your check made out to HSLC, indicating "Elementary Retreat" with student name (and adult name if applicable), in the registration slot at the counter in the Narthex. The cost is $55.00 per child, $45.00 per adult. This covers all meals and activities while at camp. Money should never be a reason to not participate - financial assistance is available. All conversations kept confidential - talk to Becky.

VERY IMPORTANT: We will also need a copy of your Insurance Card – please take a photo or make a copy and send it to Becky Cole at children@hslckirkland.org, or include the photocopy with your payment.

If you have any questions, please contact Becky at children@hslckirkland.org.

Name

First Name

Last Name

Preferred name

Gender

Grade

Current medications

Allergies

Other information we should know about your child for this event

This email address will be the one used to communicate important information about the event, so please use one that will be checked.

Parent/Guardian Name

Someone who can be reached during the event.

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone

(###)

###

####

VERY IMPORTANT: We need a copy of your Insurance Card – please take a photo or make a copy and send it to Becky Cole at children@hslckirkland.org.

I hereby give my permission for the person named above to participate in an off-site trip to Camp Lutherwood in Bellingham from March 14 through March 15, 2024 (Elementary Retreat).

Enter your initials

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

Enter your initials

As parent, or legal guardian, I authorize a qualified physician to examine the above-named youth 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.

Enter your initials

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 youth, 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.

Enter your initials

Parent/guardian name as a signature