Confirmation Retreat // MSYG 2018
Dates: November 2-4, 2018

Location: Lake Yale Conference Center
Leesburg, Florida

Cost: Confirmation Student - $100
General Participant - $200

Driving: We will use parent drivers who have been approved by the church and school.

Food: We will stop at a service station on the way to/from the gathering. Otherwise, all meals will be provided.

Sleeping: We will be housed in hotel style rooms, where students will be grouped into 3-4 people per a room.
Specific housing requests are allowed, but not always possible.

Online Flyer can be found here: https://indd.adobe.com/view/3a16c2fb-0925-4080-9351-bb45a37fc5ef

Student's Information
Step 1 of 4
First Name *
Your answer
Last Name *
Your answer
Student's Date of Birth *
MM
/
DD
/
YYYY
Student's Cell Number *
Your answer
Student's T Shirt Size *
Student's Grade *
Student's School *
Parent Information
Step 2 of 4
Mother's Name
Your answer
Mother's Cell Phone Number
Example 555-555-5555
Your answer
Would you like to receive text reminders about the CR/MSYG
Let's be honest - If you relied on your Middle schooler to give you all the information, would you know anything?
Mother's Email Address
Your answer
Father's Name
Your answer
Father's Cell Phone
Example 555-555-5555
Your answer
Would you like to receive text reminders about the CR/MSYG?
This could go either way- but it might be wise if either you or mom gets some kind of info.
Father's Email Address
Your answer
Other Information
Step 3 of 4
Address
Example 1234 Awesome Street
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Covenant
Step 4 of 4

Please read all the following information and understand the commitment and expectations of all those who plan on attending the Confirmation Retreat/Middle School Youth Gathering!

Growing in Faith *
I commit to maintaining my faith through prayer, Bible Study and Christian Fellowship.Also, I will spend time with God so I may know Him more and have Him living in me more.
Being An Example *
I commit myself to being an example of my faith and my role as a Christian during ministries at church, at youth events, at school, at work, at home and anywhere else I happen to be. I understand this also includes online and understand that my virtual life is a reflection of my real life.
Being A Light *
I commit myself to being an example, as a shining light for Jesus and as a leader among my peers and student ministry, wherever I may be. I will especially do these at the Colorado Mission trip, all events, or fund-raisers leading up to the mission trip.
Being Present *
I commit myself to being a regular attendee at middle school ministries and at St. Paul Lutheran Church worship services. I will be present at one half of all events and will encourage others to attend.
Committing My Time *
I will be on time to leave for the CR/MSYG. I will value each and every participant and chaperone's time.
Medical Release *
In consideration for participation in the 2018 Florida/Georgia District Middle School Gathering, “Real.Present.God.”, we/I, being 21 years of age or older), do for ourselves/myself (and for and on behalf of our/my “Child Participant” if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless the Florida-Georgia District of the Lutheran Church Missouri Synod, the Lutheran Church-Missouri Synod, and St.Paul Lutheran Church and School of Boca Raton and any directors, employees or agents therefrom (hereinafter collectively referred to as Designee”) thereof from any and all liability, claims or demands for 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 Child-Participant that occur while said child is participating in the above-described trip or activity. Furthermore, we/I [and on behalf of our/my Child-Participant if under the age of 21 years] hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said Designee to furnish any necessary transportation, food and lodging to this Child-Participant. The undersigned further hereby agree to hold harmless and indemnify Designee, for any liability sustained by said Designee as the result of the negligent, willful or intentional acts of said Child-Participant, including expenses incurred attendant thereto.Consent is given to the photographing of Child-Participant and the recording of Child-Participant’s voice and the use of these photographs and/or recordings singularly or in conjunction with other photographs and/or recordings for advertising, publicity, commercial or other business purposes. It is understood that the term “photograph” as used herein encompasses both still photographs and motion picture footage. Further consent is given to the reproduction and/or authorization by the Florida/Georgia District LCMS to reproduce and use said photographs and recordings of Child-Participant’s voice, for use in all domestic and foreign markets.This is an authorization under the Privacy Rules of the Health Insurance Portability and Accountability Act of 1996 [45 CFR§164.508]. We/I authorize any healthcare provider, hospital, EMT, ambulatory surgical center, walk-in health care clinic, emergency room doctor, nurse or other health care provider/entity to obtain and/or release protected health information (PHI”) regarding “Designee” as set in the “Medical and Liability Release Form”, for the purposes of obtaining protected health information from Designee or any other health care provider for the purposes of providing emergency treatment and care to “Child Participant” as that term is defined in the “Medical and Liability Release Form; use the following protected health information, and/or disclose the following protected health information to any Designee, or its director(s)employee(s), or agent(s), including, without limitation : Florida Georgia District of the Lutheran Church—Missouri SynodLutheran Church Missouri Synod. In addition to the above, the names or class of people authorized to use or disclose are as follow: Jeremiah Bauer, Director of Christian Education, St. Paul Lutheran Church & School of Boca Raton The PHI authorized herein is being used and/or disclosed in order to provide treatment and care to Child Participant and to obtain medical information about said Child Participant’s illness, injury, or medical condition. This authorization shall be in force and effect beginning on November 2, 2018 and shall remain in full force and effect until November 4, 2018 date or (2) upon such time as the Parent(s) and/or Guardian(s) are present or able to demonstrate their legal responsibility to assume such authority to obtain and disclose PHI at which time this authorization to use or disclose this authorization expires.We/I understand that we/I have the right to revoke this authorization, in writing, at any time by providing such written notification to the healthcare provider at the address where such health care is being rendered and to the attention of the healthcare provider. We/I also understand that a revocation is not effective to the extent that the healthcare provider has relied on the use or disclosure of the protected health information or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. We/I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. The healthcare provider will not condition his/her/its treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether we/I provide authorization for the requested use or disclosure except: (1) if our/my treatment is related to research, or (2) health care services are provided to us/me solely for the purpose of creating protected health information for disclosure to a third party. This Authorization for Use and Disclosure of PHI is NOT extended to any marketing efforts, which might benefit the treating healthcare provider or entity,
Photo Release
St. Paul Lutheran Church & School is allowed to use my child's photo in print and electronic communication and publications.
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