Summer Stretch Registration

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Student's Name Student's Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent/Guardian Name Parent/Guardian Name First Last
Parent/Guardian Name Parent/Guardian Name First Last
Parents Email
Parent Cell or best Emergency Number Parent Cell or best Emergency Number - ### - ### ####
Parent Cell Parent Cell - ### - ### ####
Student Cell Phone Student Cell Phone - ### - ### ####
Grade in School Fall 2018
T-Shirt Size (Adult sizes)

T-Shirt Size (Adult sizes) Small Medium Large X-Large XX-Large
I plan to participate in Summer Stretch on the following days: (Check any dates that apply to you)

I plan to participate in Summer Stretch on the following days: (Check any dates that apply to you) June 13 June 20 July 18 July 25 August 2 (Valleyfair)
Parent Signature: Draw your signature into the box below.

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.
Date Date / MM / DD YYYY
This section is for Student Leaders Only

As a high school leader, I will do my best to show the love
of Jesus to those that I work with. I will remember
that my choices are an example to others and will be an
example of Christ’s love and acceptance.
Student Leaders: Draw your signature into the box below.

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.
Date Date / MM / DD YYYY
Medical and Liability Release

I/We, the undersigned, are the parent(s), having legal custody, or the legal guardian(s) of, the minor listed on the form, and having given consent for him/her to attend Summer Stretch. In the event that he/she is injured while attending Summer Stretch and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is called for, which a physician and/or hospital personnel refuses to administer without my/our consent, I/we hereby authorize a Glen Cary Lutheran staff member to give such consent for us if I/we cannot be reached by telephone at one of the numbers listed below, or because of an emergency there is not time to make a telephone call.
In the event it becomes necessary for that person to give consent for us, I/we agree to hold such persons free and harmless of any claim, demands, or suit for damage arising from the giving of such consent so long as the treatment is administered by or under the supervision of a licensed physician. I/we also acknowledge that I/we will be ultimately responsible for the cost of any medical care that is not reimbursed by the health insurance carrier. Further, I/we affirm that the health insurance information provided below is accurate at this date and will, to the best of my/our knowledge, still be in force for the child named above during the weeks of Summer Stretch.
I understand that there are inherent risks involved in any church youth event, and I/we hereby release Glen Cary Lutheran Church, its staff and volunteer workers from any and all liability due to injury, loss, or damage to person or property that may occur during the course of my/our involvement with Summer Stretch.
Name of Health Insurance Policy Holder
Policy Holder’s Phone Number
Health Insurance Policy Number
Policy Holder’s Employer
Telephone Number of Policy Holder’s Employer Telephone Number of Policy Holder’s Employer - ### - ### ####
Signature of person authorizing medical care

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.
Date Date / MM / DD YYYY
Known allergies and/or medications
Date of Last Tetanus Shot

Summer Stretch Registration

Summer Stretch Registration

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This section is for Student Leaders Only

Medical and Liability Release

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