FALL RETRAT 2018 NOV 16, 17, 18 (FRI-SUN)
LPC STUDENTS FALL RETREAT
Date: November 16, 17, 18 (7pm Friday - Noon Sunday)
Cost: $85 - Early Bird Registration through Nov 4th is $85 ($90 after that)
Who: All 7th-12th graders
What: A great weekend of outdoor games, crazy fun, worship, messages and lots of laughs.

TIme/Location:
7pm on Friday, November 16 (Meet at LPC 123 N East St Lebanon, OH)
Retreat at Woodland Lakes Camp in Amelia, OH (3054 Lindale Mt. Holly Road Amelia, OH)
12pm (Noon) on Sunday, November 18

Questions? Email: andrew@lebanonpresbyterian.org

Student First Name *
Your answer
Student Last Name *
Your answer
How did you hear about The Fall Retreat *
Who is your friend?
Your answer
Have you invited a friend yet? *
Student Age *
Student T-Shirt Size *
Student Grade *
Your answer
Student School *
Your answer
Student Mobile Phone # *
XXX-XXX-XXXX (if you don't have one type: I don't have one :-)
Your answer
Student Email *
Your answer
Parent(s) Name *
Your answer
Parent Mobile Phone # *
XXX-XXX-XXXX
Your answer
Parent Email *
Your answer
Family Address *
### Street St City, State ZIP
Your answer
Date of last known Tetanus Booster *
(If you can find it) Month & Year
Your answer
Medications: Name of Medicine, For What & Dosage
Your answer
Allergies & Menu Restrictions
Your answer
Activity Limitations
Your answer
Recent Illness
Your answer
Other Comments &/or Helpful Instructions regarding your student
Your answer
Name of Designated Adult Emergency Contact 24hr *
Your answer
Phone of Designated Adult Emergency Contact 24hr *
Your answer
Relationship of Designated Adult Emergency Contact 24hr *
Your answer
EMERGENCY MEDICAL AND DISCIPLINARY RELEASE *
I understand that all due precautions will be taken, but in spite of this, accidents can happen and illness develop; therefore I will not hold the leaders or directors of the church liable for any illness or accident resulting from the above named child's participation. In case of surgical or medical emergency, I hereby give permission to the physician sponsored by the leaders or directors to hospitalize secure proper treatment, ordering of injection, anesthesia, for the child named above and cover any costs associated with said treatment. I also agree to pay any expense, including the cost of my child being sent home if disciplinary action is deemed necessary. The parents of those students not at the departure vehicles within a reasonable allowance of the designated time will be notified that they must arrange for their student's transportation home. ...........................................................................................................................................................
PARENTAL CONSENT & LIABILITY RELEASE *
Parental Consent The undersigned ("Legal Guardian") does hereby give permission for my child (LISTED ABOVE)(“Participant”), to attend and participate in any Lebanon Presbyterian Church children/youth ministry activities, events, retreats and childcare during the period of September 1, 2018– August 31, 2019. LIABILITY RELEASE: In consideration of Lebanon Presbyterian Church allowing the Participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Lebanon Presbyterian 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 children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and child care, 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. .........................................................................................................................................................................
TRANSPORTATION PERMISSION: *
The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Lebanon Presbyterian Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. ....................................................................................................................................................................................
SIGNATURE EMERGENCY MEDICAL, DISCIPLINARY, PARENTAL CONSENT, LIABILITY RELEASE, TRANSPORTATION PERMISSION: I am the Parent and/or Guardian of Student listed above and agree to the above statement of responsibility, release, and give my consent to the preceding statement. By typing my name in this line I am signing my name. *
("Legal Guardian") Parent First & Last Name
Your answer
Reminder on the info
LPC STUDENTS FALL RETREAT
Date: November 16, 17, 18 (7pm Friday - Noon Sunday)
Cost: $85 - Early Bird Registration through Nov 4th is $85 ($90 after that)
Who: All 7th-12th graders
What: A great weekend of outdoor games, crazy fun, worship, messages and lots of laughs.

TIme/Location:
7pm on Friday, November 16 (Meet at LPC 123 N East St Lebanon, OH)
Retreat at Woodland Lakes Camp in Amelia, OH (3054 Lindale Mt. Holly Road Amelia, OH)
12pm (Noon) on Sunday, November 18

Questions? Email: andrew@lebanonpresbyterian.org

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