St. Peter Youth Ministry Winter Camp Permission 2026
St. Peter Youth Ministry Winter Camp Permission 2026
We will be going to Lake Geneva Youth Camp for the weekend of Feb 20 - 22
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Participant Name(s)
Participant Name(s)
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First
Last
Birthdate
Birthdate
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/
MM
/
DD
YYYY
Gender
*
Gender
Male
Female
Address
Address
*
Street Address
Address Line 2
City
Postal / Zip Code
Email
*
Parent or Guardian Emergency Contact
Parent or Guardian Emergency Contact
*
First
Last
Phone Number
Phone Number
*
-
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Second Parent or Guardian Emergency Contact
Second Parent or Guardian Emergency Contact
*
First
Last
Phone Number
Phone Number
*
-
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-
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If not available in an emergency, notify:
If not available in an emergency, notify:
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First
Last
Phone Number
Phone Number
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Medical Information
Please list any known allergies or medical conditions of the child below, along with any extra information that could be useful to St. Peter chaperones or medical professionals:
Please take a clear picture of the FRONT of your insurance card. Upload the file here.
*
Please take a clear picture of the BACK of your insurance card. Upload the file here.
*
Travel Release and Hold Harmless Agreement
I am the parent or legal guardian of the above-listed participant (a minor), who desires to participate in various programs, events, or activities operated or sponsored by St. Peter Lutheran Church, Arlington Heights, Illinois. I understand and acknowledge that St. Peter will not allow my child to participate in any activities without releasing the holding St. Peter harmless from any liability arising out of participation in the activities. I have investigated the risk involved in my child’s participation in the activities and full understand and assume such risks on my behalf. Specifically, I understand and acknowledge that my child may suffer or experience, among other things, personal injury or bodily damage, medical disabilities, loss or theft of personal property, imprisonment, abduction, and even death. I REQUEST THAT THE CHURCH ALLOW MY CHILD TO PARTICIPATE IN THE ACTIVITIES, AND IN CONSIDERATION THEREOF AGREE HEREBY TO RELEASE AND FOREVER DISCHARGE THE CHURCH, ITS OFFICERS AND DIRECTORS, AND ITS EMPLOYEES, AGENTS, AND ANY PARTIES VOLUNTEERING ON BEHALF OF THE CHURCH, FROM ALL ACTIONS, CAUSES OF ACTION, INJURIES, CLAIMS, DAMAGES, RANDOM DEMANDS, COST OR EXPENSES OF ANY KIND, GROWING OUT OF OR RELATED TO ANY SUCH ACTIVITIES IN WHICH THE CHILD PARTICIPATES. I UNDERSTAND THAT THIS IS A FULL AND COMPLETE RELEASE OF ALL INJURIES AND DAMAGES WHICH I OR THE CHILD MAY SUSTAIN AS A RESULT OF HIS/HER PARTICIPATION IN ANY OF THE ACTIVITIES, REGARDLESS OF THE SPECIFIC CAUSE THEREOF. I acknowledge and agree that I have given my consent for my child to remain in custody of the St. Peter’s representatives while participating in the activities. The Agreement is binding on my child’s, successors and personal representatives.
*
Draw
or
Type
Please initial here.
Clear
Full Name
Please initial here.
Medical Treatment Authorization and Power or Attorney
In the event my child suffers an injury or condition during his/her participation in the activities, including transportation to and from an activity, which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me or my spouse have been unsuccessful, I hereby appoint St. Peter Staff, including paid and volunteer workers, as my agent to act for me in my name (in any way I could act in person) to make any and all decisions for my child concerning his/her personal care/medical treatment, hospitalization and health care. This power of attorney and delegation of authority will terminate when the agent is first able to contact me or my spouse.
*
Draw
or
Type
Please initial here
Clear
Full Name
Please initial here
Photography Release
Regarding photographs of my child taken at any St. Peter Lutheran Church event, I give St. Peter permission to do the following for nonprofit use and without charge: use at the discretion of St. Peter, display at a service, event, on websites, blogs, other internet communications, or be used in a multimedia presentation. I also allow the photographs taken to be reprinted and distributed for any St. Peter non-profit publications with copyright to accompany photo when necessary. I also allow use of quotes and/or video clips for the above mentioned purposes.
*
Draw
or
Type
Please initial here.
Clear
Full Name
Please initial here.
Parent or Guardian Signature
The undersigned, as the legal parent or guardian of, a minor, agree to the above initialed sections and this agreement is binding on my heirs, successors and personal representatives.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
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Submit