Youth Mission Trip - Registration & Waiver 2025

Student T-Shirt Size

Youth L Adult S Adult M Adult L Adult XL

I, the Parent/Guardian of__________. (Enter CHILD'S FIRST NAME BELOW)

Their Name (child's name)

Birthdate

How old are they?

13 14 15 16 17 18 19

Current 2024-25 School Grade

8 9 10 11 12

ROOMING BUDDY
Does your child have a preference of a Rooming Buddy? We can't necessarily guarantee they'll end up together, but it is helpful knowing. Enter their first and last name below, or skip to the next question.

First and Last name of preferred buddy:

Youth Mobile Phone

Youth Email

Address

Approval

Hereby give my approval to his/her participation in any and all activities of Fox Point Lutheran Church during the period of September 1, 2024 through August 31, 2025. I assume all risks and hazards incidental to such participation, including transportation to and from activities. I do hereby waive, release, absolve, and indemnify the church, its servants, and participants, as well as transporting the above named child to and from related activities, for any injury or action resulting in a medical claim. I also give the physician/hospital selected by the program supervisor permission to secure proper treatment for my child, should it become necessary. I also assume responsibility of all medical expenses incurred. Should it be necessary for my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Approval Signature

Do you approve the Approval?

Approve

Parent/Guardian Signature (enter Parent's first and last name)

Today's Date

Guardians & Emergency Contact

Parent/Guardian #1 First Name

Parent/Guardian #1 Last Name

Are you interested in chaperoning?

Yes No Not sure yet

Mobile Phone

This address will receive a confirmation email

Parent/Guardian #2 Name

Are they interested in chaperoning?

Yes No Not sure yet

Mobile Phone #2

Email #2

This address will receive a confirmation email

Emergency Contact Person OTHER THAN PARENT (first and last name)

Emergency Mobile Phone

Relation to Child

Medical Waiver

Insurance

Insurance Company:

Policy Number

Insurance ID Number:

Physician’s Name

Physician’s Phone Number

Known Allergies

Special Dietary Restrictions

Special Medical Conditions/Concerns

Medications - include instructions/dosages

Date of Last Tetanus Shot

FUNDRAISING

Our Goal is to raise $10,000 to help with this trip! By participating in a minimum of 2 fundraiser events/or dates it will help drop the price by $100!! Please consider signing up for at least two.

Below is our Kringle Fundraiser. Sign up for 1 or more dates!

Time: 10am - 11:45am
Location: Fellowship Hall

Kringle Fundraiser

Sun., March 23 Sun., March 30 Sun., April 6 Sun., April 20 None

Payment

TODAY'S DEPOSIT
$600 - Deposit is due at the time of submitting this form. Because of the airfare, only $100 is refundable by May 1, 2025.

FINAL PAYMENT
Due by May 1, 2025. (An invoice for the remaining $600 balance will be sent to you via email.)

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Youth Mission Trip - Registration & Waiver 2025

Description

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