Soularise Day Camp – Family Registration

Family Name *

Number of Adults Attending

Number of Children Attending

Parent/Guardian's Name (Primary emergency contact) *

Parent/Guardian's Mobile Number *

Parent/Guardian's Address *

Parent/Guardian's Email *

Parent/Guardian's Name (Optional)

Parent/Guardian's Mobile Number (Optional)

Parent/Guardian's Address (Optional)

Parent/Guardian's Email (Optional)

Secondary Emergency Contact Name & Number (May be same as second listed Parent/Guardian, or another adult) *

Any Medical Conditions/Needs?

Any Dietary Requirements or Food Allergies?

Information Storage Consent (Required) *

I consent to this information being stored by Immanuel Lutheran Church. It will be used only for youth ministry in accordance with the LCAQD Privacy Policy.

First Aid & Indemnity Consent (Required) *

I agree that in the event of a medical emergency where I cannot be contacted that leaders will arrange the best possible medical care. I agree to pay in full for all medical costs involved. I will not hold liable Immanuel Lutheran Church or its agents for any loss or injury incurred.

Photo Consent (Optional)

I consent to the use of photos of myself and my family for promotional purposes within Immanuel College or Immanuel Church.

FAMILY COMMITMENT (Required) *

We will respect people and help everyone have a good, safe, and fun time.
If we are disrespectful or make people feel unsafe then we may not be allowed to participate in activities, we may be asked to leave.
We understand that Immanuel Youth is completely drug and alcohol free.

Parent/Guardian's Full Name in BLOCK LETTERS *

Date *

Comment

Immanuel Lutheran Church Buderim