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2018 LSSNCA -Youth Haven Participant Registration
Walking with families affected by social stigma to raise up young people
who are healthy, connected , and succeeding.
Email address *
Participant Full Name: *
Please provide First AND Last Name
Your answer
Participant Phone Number *
Your answer
Best Way to Contact *
Date of Birth: *
Your answer
Age: *
Your answer
Gender: *
Street: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Parent/Guardian Name: *
Your answer
Parent/Guardian Relationship to camper: *
Your answer
Phone 1: *
Your answer
Phone 2:
Your answer
T-shirt size:
Allergies/Special Dietary Needs: *
Your answer
Have you attended a support group session? *
Which program(s) are you interested in : *
Required
School Name:
Your answer
School District:
Your answer
School Grade/Education Level: *
Your answer
Write the names of family members who also attend Youth Haven programs :
Your answer
Signature of person completing this registration *
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Date: *
MM
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DD
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YYYY
For statistical purposes only:
Camper Race/ethnicity: *
Required
Number and Relationship of Persons in household: (Ex. #5; grandmother, dad, 2 foster sisters, 1 brother) *
Your answer
Head of household : *
Your answer
LIABILITY RELEASE
PLEASE READ THE FOLLOWING AGREEMENT AND WAIVER CAREFULLY, AS THIS AGREEMENT INCLUDES RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK AND AN AGREEMENT TO INDEMNIFY THE RELEASEES.
BY PROCEEDING WITH REGISTERING FOR THIS PROGRAM, YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE CAREFULLY READ THE AGREEMENT AND WAIVER AND AGREE TO THE TERMS SET FORTH BELOW.
Please note that an esignature is the electronic equivalent of a hand-written signature.
I release Youth Haven, Lutheran Social Services/NCA, its directors, medical, volunteer and staff persons and all funders from any and all liability resulting from my child’s involvement in programs created by Lutheran Social Services. I know that in order for my child to be considered for inclusion, all forms must be filled out completely, clearly, and honestly. I understand that every effort will be made to maintain a safe and healthy environment for all those involved in camp activities. It is with this understanding that I release all staff and subsidiary and support staff (including nurses, doctors, hospital workers, administrators, drivers, cooks, counselors, fund-raisers, board members and directors) from any implied or direct liability. I understand that if my child requires medical attention, every reasonable effort will be made to contact me or my agents as listed above regarding such treatment. But in case I am unreachable and treatment is necessary, I provide on additional pages attached here, full medical information including insurance information as well as a separate release for medical treatment. By clicking below, typing your (if UNDER 18 years of age, Parent or Guardian) Name AND Date, you are agreeing to the terms above. *
Your answer
EMERGENCY MEDICAL TREATMENT AUTHORIZATION
PLEASE READ THE FOLLOWING AGREEMENT AND WAIVER CAREFULLY, AS THIS AGREEMENT INCLUDES RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK AND AN AGREEMENT TO INDEMNIFY THE RELEASEES.
BY PROCEEDING WITH REGISTERING FOR THIS PROGRAM, YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE CAREFULLY READ THE AGREEMENT AND WAIVER AND AGREE TO THE TERMS SET FORTH BELOW.
Please note that an esignature is the electronic equivalent of a hand-written signature.
I do hereby authorize and permit Lutheran Social Services of the National Capital Area (LSS/NCA) to bring my child to the hospital or emergency room or clinic for evaluation and or treatment. I understand that, if possible, my child’s primary physician will be contacted so that he/she may participate in this treatment in the event of an emergency. In the event that my child’s primary physician is not available, I hereby authorize the physicians and staff on duty at the hospital or clinic to treat my child in the event of such an emergency (illness, accident or other injury). I realize that all costs incurred as a result of this treatment may be billed directly to me if proper payment information is not included above. I understand that LSS/NCA will not be liable for any costs related to emergency treatment of my child. By my signature below, I release LSS/NCA, its entire staff, volunteers, nurses, and support personnel, as well as the medical and administrative staff of the treating hospital or medical facility, local EMTs ambulatory services, clinical staff and nurses, funders, from any and all liability resulting from action caused by such an emergency. By clicking below, typing your (Parent or Guardian) Name, your child (Participant) Name AND Date, you are agreeing to the terms above. *
Your answer
PERMISSION TO TRANSPORT
PLEASE READ THE FOLLOWING AGREEMENT AND WAIVER CAREFULLY, AS THIS AGREEMENT INCLUDES RELEASE AND WAIVER OF LIABILITY, AN ASSUMPTION OF RISK AND AN AGREEMENT TO INDEMNIFY THE RELEASES.
BY PROCEEDING WITH REGISTERING FOR THIS PROGRAM, YOU ACKNOWLEDGE AND AGREE THAT YOU HAVE CAREFULLY READ THE AGREEMENT AND WAIVER AND AGREE TO THE TERMS SET FORTH BELOW. eSignature
Please note that an esignature is the electronic equivalent of a hand-written signature.
Youth Haven Camps and Retreats, Lutheran Social Services/NCA, has permission to transport my child to and from the camp activities and release its directors, drivers, volunteer and staff persons and all funders from any and all liability resulting from my child’s participation in such transportation. I understand clearly that every effort will be made to provide safe transportation. I have read and agreed to the camp transportation policies and procedures. I understand that I am responsible for getting my child to the drop off location by the time listed and for picking up my child at the time listed. I understand that while the camp staff will not leave my child alone, if I do not inform them of delays or changes, or if additional costs are incurred to get my child home after camp because I have not followed the policies, my child may not be invited to participate in future camp programs. By clicking below, typing your (Parent or Guardian) Name, your child (Participant) Name AND Date, you are agreeing to the terms above. *
Your answer
Names of others with permission to pick-up/ drop-off your child: *
Your answer
Does your child have your permission to metro home alone? *
EMERGENCY CONTACT INFORMATION
Name of person to call if Parent / Guardian is not available AND Relationship to camper: *
Your answer
Phone number(s) of person to call if Parent / Guardian is not available: *
Your answer
Health Insurance Company: *
Your answer
Policy #: *
Your answer
Insurance Co. Phone: *
Your answer
Group Number: *
Your answer
Primary physician name: *
Your answer
Primary physician phone number(s): *
Your answer
Social Worker / Case Manager / Psychiatrist Name(s): *
Your answer
Social Worker / Case Manager / Psychiatrist Phone(s): *
Your answer
Please CHECK any medications listed below that you WILL ALLOW your child to be given by the nursing staff: *
Required
By clicking below, typing your (if UNDER 18 years of age, Parent or Guardian) NAME AND Date, you are agreeing to the statement above. *
Your answer
HOW CAN CAMP STAFF SUPPORT YOUR CHILD?
Your answer
OTHER COMMENTS OR CONCERNS:
Your answer
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