SUMMIT Emergency Contact and Liability Form
We look forward to working with you and your student this year!  Please contact Mike Iversen at 920-722-8918 for questions about this form.  SUMMIT begins on Tuesday September 8 and runs until Tuesday May 4. Please fill out one form for each student. Additional details and calendar changes can be found here: www.spiritusministries.org/summit
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Email *
Student First Name 
Student Last Name 
Student Birthdate *
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Parent Name (First and Last) 
Parent Phone Number
Mailing Address (street, city, zip)
Emergency Contact Name (if Parent can't be reached)
Emergency Contact Phone Number
Parish/Church Name
LIABILITY FORM:  I give permission for the above named student to participate in events organized by SPIRITUS Ministries.  I understand that some activities may include offsite events, within walking distance of the Mount Tabor Center at 522 Second Street in Menasha. As a parent and/or legal guardian of the above named student, my agreement below indicates I remain legally responsible for any actions on the part of the student.  I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, to hold harmless and defend SPIRITUS Ministries and the Mount Tabor Center, Inc. its officers, board members, employees and missionaries from any claim arising from or in connection with my child attending the event or in connection with any illness or injury (including death) or cost of medical treatment in connection therewith, and I agree to compensate SPIRITUS Ministries and the Mount Tabor Center, Inc. its officers, board members, employees and missionaries for reasonable attorney’s fees and expenses which may incur in any action brought against them as a result of such injury or damage, unless such claim arises from the negligence of SPIRITUS Ministries and the Mount Tabor Center, Inc. 
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Photo Release:  I give my consent for my child's image or likeness to be included in media pieces for purposes of marketing and promotion of SPIRITUS and SUMMIT.
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