Youth Night Saturday January 18th

This is not a lock-in (overnight)
After feedback and assessment we are trying something new this year. Instead of an overnight with a bunch of hormonal teenagers, hyped up on Mountain Dew, running around for several hours, with a mess of exhaustion and messed up sleep schedules for days after the event we are doing an afternoon/evening event. Nothing good happens after 3 a.m. and our students are already exhausted from busy lives. So this year we are opting for a afternoon/evening youth event where students go home to their own beds at 11pm.

Youth Name

Youth Birthdate

Youth Cell Phone (if applicable)

Are you are friend of one of the Hope Lutheran Youth? If so please name here.

Present Grade in school

6th 7th 8th 9th 10th 11th 12th

Address

Parent/Guardian #1 Name

Parent Cell Phone

Other Phone (if applicable)

This address will receive a confirmation email

Emergency Contact (should above parent not be reached)

Relationship to Youth:

Emergency Contact Cell Phone

Emergency Contact Alternate Phone (if applicable)

Medical Insurance Company

Policy Holder's Name

Policy/Certificate Number

Does the participant have any allergies?

Yes No

If yes, please list and/or explain type of allergies and reaction:

Please list any medications being taken, medical problems, or other pertinent information including physical, mental, or psychological conditions that may require medication, treament or restrictions:

Are you as parent/guardian willing to help with this event? Yes-I can be a driver to/from Escape Room (3pm-5pm) Yes-I can be a driver for evening service projects (5-7pm) Yes-I can chaperone for part or all of the event Yes-I can help prepare evening meal on-site Yes-I can help please contact me for specifics No thanks :)

NOTE: A portion of this will involve an off site service project (split in groups to Hastings Family Service or Vets Home), as well as traveling to Escape Room St. Paul.

Additional release forms from our 3rd party locations including the Escape Room St. Paul and our volunteer locations (HFS & Vets Home) will be required and sent out as the date gets closer.

The undersigned hereby gives permission for my child to ride in a vehicle driven by an approved and licensed ADULT chaperone (25 years of age or older) while attending and participating in activities sponsored by Hope Lutheran Church. I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

I agree I DO NOT agree

Photo Image Release: As a participant in a Hope Lutheran Church event, I give permission and consent to allow photos, and videos, to be taken of the above mentioned individual during the event. I further give consent that any such images or videos may be published in a variety of ways and used to illustrate and promote Hope Lutheran Church.

I agree I DO NOT agree

Authorization for Treatment: I hereby authorize the Hope Lutheran Church staff and volunteers to administer medications and first aid as deemed necessary as well as authorize the medical personnel selected by Hope Lutheran Church Staff to provide emergency medical care by medical staff to hospitalize, secure treatment for, order injection, anesthesia, blood transfusions, or surgery, and to release any records necessary for insurance purposes as well as provide or arrange necessary related transportation for the above named participant. This form may be photocopied.

I agree I DO NOT agree

Event is FREE for all to attend. If you would like to make a donation to help cover cost of event (Escape Room, Food, supplies) you may do so here.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Youth Night Saturday January 18th

Description

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