November 17-19, 2017

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1 NE District High School Youth Gathering 9th-12th grade vember 17-19, 2017 LaVista Conference Center Omaha, Nebraska $200/person Registration Deadline: October 1st (Scholarships available) Late registration fee: $35 How to register: Return completed forms (listed below) and a $135 non-refundable deposit to Julie Keeley. Checks may be out to Peace Lutheran Church with HS NE-YG in the memo line. Drop-off and Pick-up at Peace Lutheran Church. Leave on Fri., v. 17 at 3:30pm. Return on Sun., v. 19 at 3:30pm. Forms Checklist: Emergency Information Form (For NE district) *Participation Agreement and Liability Waiver (For Peace Lutheran) *Medical Information Form (For Peace Lutheran) *Behavior Expectations Form * These forms only need to be turned in once per school year for all events. For more information, contact Julie Keeley at or Sponsored by the Nebraska District LCMS

2 EMERGENCY INFORMATION FORM *Make copies of this form for EACH participant. Once completed, please make two copies of this information (Send original with registration materials; keep one with the Family Group Leader; and keep one with the participant) Name: (Last) (First) (Middle Initial) Mailing Address: (Street) (City) (State) (Zip) Male: Female: Age: Date of Birth: (MM/DD/YEAR) Parent s Name(s) (if under age 21): Parent s Phone - Home ( ) Cell1( ) Cell 2( ) HEALTH INFORMATION: To be completed by ALL Participants Please explain special diet and health arrangement needs: General: Do you have: (If yes, please explain) Allergies? Heart? Other? Are you subject to: (If yes, please explain) Fainting? Sleep Walking? Upset Stomach? Other? Do you have reaction to (If yes, please explain). Bee Sting? Penicillin? Other Drugs? Poison Ivy, Oak, Sumac? Other? Have you had any serious illness or surgery within the past ten years? Do you have any condition that would prevent you from participating in any activities? Please list: Are you diabetic? Do you have any sight or hearing impairment? Do you wear contact lenses? Date of last Tetanus shot: Please list ANYTHING else the leaders should know to help avoid or deal with any situation that might arise: INSURANCE INFORMATION: MUST BE INCLUDED Health Insurance Co.: Policy.: Name of policy holder: Name of another person to contact: Friend/Relative Address: (Street) (City) (State) (Zip) Telephone: Home( ) Work( ) Family Doctor s Name: Work Phone ( ) Family Dentist s Name: Work Phone ( ) Do any pre-certification, notification, or other requirements exist with respect to the health insurance participant? If so, specify COMPLETE OTHER SIDE OF PAGE

3 AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE PERMISSION TO ATTEND FORM For participants under 21 years old: I/We, the undersigned parent(s) and/or natural guardian(s) of, a minor, do hereby authorize my/our child s youth leader or an agent of the Nebraska District of The Lutheran Church Missouri Synod to arrange for such medical, dental, or hospital treatment as deemed advisable for the health and well-being of the above named minor during the Nebraska District Jr. High Gathering. I/We understand that an attempt will be made to notify the parent(s)/guardian(s) first. However, if parent(s)/guardian(s) are not available, or if the need for medical attention is immediate, the above authorization will be used. I/We understand that this authorization is given in advance of the occurrence of any condition or situation that would necessitate any such medical, surgical, or dental care, but is given to provide authority to obtain such care if it should be required. I/We give permission for my/our child to attend and fully participate in the Nebraska District Jr. High Gathering (please refer to the activities listed on the enclosed sheet). I/We give the Nebraska District the right to use the image and comments of my/our child/ward for publicity and news release purposes. I understand I will not be given any creative control over the finished use of the image. I understand that neither I, nor my minor child/ward are or will be compensated for this participation. I/We fully understand the consequences of the foregoing statements and sign this EMERGENCY INFORMATION/AUTHORIZATION TO CONSENT TO MEDICAL AND DENTAL CARE/ PERMISSION TO ATTEND FORM knowingly, freely, and willingly. Signature: (parent/guardian signature) Signature: (parent/guardian signature) Witness: For participants over 21 years old: I certify that I am at least 21 years old. I hereby agree to serve as an adult leader and to participate fully in the Nebraska District Jr. High Gathering. I will supervise and care for all members of my Family Group throughout the Gathering experience. I grant the Nebraska District permission to use still or video images of my person and my comments for publicity and news release purposes. I understand I will not be given any creative control over the finished use of the image. I understand I will not be compensated for this participation. Signature: (Family Group Adult Leader signature)

4 High School Youth Ministry Program Participation Agreement YOUTH PARTICIPANT INFORMATION Effective Dates: September 1, 2017 August 31, 2018 Name of participant: DOB: Male Female Nickname: School: Grade entering in Fall 2017: 9 th 10 th 11 th 12 th Graduated Youth Primary Address: Youth Youth Home Phone: Youth Cell Phone: PARENT/ GUARDIAN INFORMATION Name(s): (s): List all phone numbers where the parent(s)/guardian(s) can be reached (type: i.e. home, cell) EMERGENCY CONTACT Name # Relation? Name # Relation? PARENTAL CONSENT: The undersigned does hereby give permission for my child, (child s name), to attend and participate in any Peace Lutheran Church High School Youth Ministry Program activities including, but not limited to, events such as Sunday School, youth group nights, trips, lock ins, and retreats during the period of 9/1/2017 8/31/2018. LIABILITY RELEASE: In consideration of Peace Lutheran Church allowing the Participant to participate in the High School Youth Ministry Program (Sunday School, Youth Group Nights, lock ins, retreats, trips, and other related events), I, the undersigned, do hereby release, forever discharge and agree to hold harmless Peace Lutheran Church, its pastors, directors, employees, volunteers and teachers (collectively herein the Church ) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in Youth Ministry Program activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto. EARLY HOME POLICY: Should it be necessary for my child to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Peace Lutheran Church. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. Parent s/guardian s Printed Name: Parent s/guardian s Signature: If the participating youth is 19 years of age or over: Youth s Printed Name: Youth s Signature: 1 of 1

5 YOUTH PARTICIPANT (Please Print) High School Ministry Program Medical Release Form Effective Dates: September 1, 2017 August 31, 2018 Youth Full Name DOB: PARENT/GUARDIAN Parent/Guardian Name(s): PRIMARY CARE PHYSICIAN Name: Name of practice: Phone(s): INSURANCE INFORMATION Medical Insurance Company: Phone: Policy Holder s Name: Policy/Group ID#: MEDICATION: List all medications the youth will take during any youth ministry program events. This includes any prescription, non prescription medications, herbal supplements and vitamins. Any youth participant in a Youth Ministry program is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non prescription medication and will be sent home at the parent/guardian s expense if they do. Medication Name Dose Treatment for Dispensing instructions Example: Zyrtec 5mg Seasonal allergies Take one pill daily in the morning with food OVER THE COUNTER MEDICATION PERMISSION: Do you give permission for your child/youth to be given over the counter medication as needed and as directed on the label, to treat nonemergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry program event? NO. Contact me or get medical help if my child has any emergency medical concerns. Parent signature: YES. I give permission for an adult leader to give my child approved emergency prescription medications as directed on an as needed basis to treat emergency medical conditions. Parent Signature: MEDICAL TREATMENT PERMISSION AND AUTHORIZATION: I understand that my or my minor child s/ward s presence at and participation in Peace Lutheran Church s program or activity presents varying degrees of certain risks some of which are unknown which may arise from a condition of the premises at which the program or activity is held; from the action of any person in connection with the preparation for, supervision of or conduct of any activity whether planned or unplanned; or from foreseeable or unforeseen elements or factors. I hereby give informed and expressed consent for this individual to take part in all activities under supervision, and agree that the church or church personnel will not be held responsible for accidents arising there from. I authorize the designated church staff to provide appropriate treatment to this individual for injuries and/or illness. This includes, but is not limited to, following Peace Lutheran Church s medical procedures and protocols, following poison control recommendations, administering prescription medications as noted above, administering over the counter medications as approved above, transportation to clinic or hospital care, and following directions from the medical director. I understand that the information on this form may be released to the appropriate medical personnel in case of emergency. I agree to pay any cost for medical care in the event of an emergency, even if I do not have health insurance coverage or not all costs are covered by insurance. I also understand that failure to disclose medical or emotional problems in advance may lead to serious consequences while at a church activity/program. Lastly, I verify that everything contained on this form is complete and accurate, to the best of my knowledge. Parent s/guardian s Printed Name: Parent s/guardian s Signature: If the participant is 19 years of age or over: Participant s Printed Name: Participant s Signature: 1 of 2

6 HEALTH HISTORY Emergency Medical Information Form If : If : If : If : If : Sight or Hearing Impairment Recurrent Headaches Heart Disease or Problems Diabetes ADD or ADHD Contacts Epilepsy or Convulsions Ear, se, or Throat trouble Anxiety, or Depression Motion Sickness Hearing Aids Asthma Stomach or Intestine trouble Dizzy Spells or Fainting Sleepwalking Disease or injury to joints or back Comments, other issues, physical limitations and/or list surgeries ALLERGIES Type of Allergy Describe/Specify Allergen Severity of Reaction (please check one) Describe Reaction Food Medication Environmental (animal, plant, insect, etc.) Other Blood Type (if known): Date of last tetanus shot (or estimated date): SWIMMING ABILITY: n swimmer Beginner Advanced MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages if necessary. 1. List any other medical conditions the participant may have that are not listed in the above table. 2. Does the participant have any condition that would prevent him/her from participating in any particular activity? Please list. 3. Are any drugs ineffective in treatment? 4. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know. 2 of 2

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