2022 Student Ministries Summer Retreat Registration

Student First Name *

Student Last Name *

Date of Birth *

Age *

Grade as of Fall 2021 *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Phone *

Parent/Guardian Address *

Street Address Line 2

City State

Emergency Contact Name *

First Name Last Name

Emergency Contact Phone *

Early Departure: Only those authorized can remove a student from the retreat early. List designated person(s). *

Student's Physician *

Phone *

Insurance Co. *

Policy # *

Does the Student have allergies? *

Yes No

If yes, please explain

Can a Student Ministries staff member give your student Tylenol? *

Yes No

If No to Tylenol is there an Alternative

Can a Student Ministries staff member Benadryl? *

Yes No

If No to Benadryl is there an Alternative

Can a Student Ministries staff member Ibuprofen? *

Yes No

If No to Ibuprofen is there an Alternative

Student may be given over the counter, non-prescription medications or applications, not to exceed the recommended dosage for stomach discomfort, burns, cuts, insect bites, rash or scrape

Does the Student have: Heart Trouble *

Yes No

Does the Student have: Ear Trouble *

Yes No

Does the Student have: Asthma *

Yes No

Does the Student have: Sleepwalking *

Yes No

Does the Student have: Seizures *

Yes No

Other explain:

Current Medications Student is taking: (Please remember that medications HAVE to come to the retreat in their ORIGINAL CONTAINER. (This includes: over the counter medications, inhalers, and vitamins)

Time of Day Taken/Special Instructions

Medication Name & Dose

Reason & Time of Day Take/Instructions

Medication Name & Dose

Reason & Time of Day Take/Instructions

Medication Name & Dose

Reason & Time of Day Take/Instructions

Please list any additional medical/health needs your child may have arise during their time at the retreat

Medical Consent: I, Parent Name* grant permission for Abundant Life Student Ministries Staff to give my child (name listed above) the medications listed above during their time at Student Ministries Summer Retreat.

Signature *

Clear

Date *

Date

Step #4 Parental & Student Consent

I hereby grant permission for my child, named above to attend the Abundant Life Student Ministries Summer Retreat in Heber, UT. I further release my child into the custody of the adults from our church who are attending the retreat. Furthermore, I grant permission to the Abundant Life Student Ministries staff to hospitalize and secure proper treatment (including surgery) for my child. It is understood that the Retreat leadership will make a conscientious effort to locate me or the emergency contact listed on this form. I will fully pay for all medical expenses, not covered by the child's insurance.

I/We understand that if any rules are not followed could result in immediate removal from the Summer Retreat trip and you will be sent home immediately.

I/We understand that all Abundant Life Student Ministries events and trips are a privilege to attend and NOT a right. Failure to follow rules can result in loss of that privilege.

I/We also understand that participants at The Summer Retreat are liable for damages caused intentionally or maliciously. Damage caused by a participant will be billed directly to the participant responsible and their legal guardian. I understand that the Summer Retreat is a voluntary activity. Students must be willing to withoverall spirit and schedule of The Retreat. We reserve the right to search personal belongings for suspected contraband for the safety the cooperate and protection of all.

I/We understand all reasonable precautions will be taken at all times by Abundant Life Student Ministries and its leaders during the events and activities. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We understand activities during the retreat may include but are not limited to swimming, boating, Alpine Slide, and more. I/We agree not to hold Abundant Life Assembly of God or Abundant Life Student Ministries, its leaders, employees, and volunteer staff liable for damages, losses, or injuries incurred by the subject of this form.

My students photo may be used for promotional material and social media. Parent Initials *

I have reviewed the Parental & Student Consent. Student/s signature below confirms his/her agreement to abide by camp policies including dress code.

Parent Signature *

Clear

Date *

Date

Student Signature *

Clear

Date *

Date

2022 Student Ministries Summer Retreat

Step #1: Please complete with Student Information:

Step #2: Please complete with Parent/Guardian Information:

Step #3: Medical Information: all medications, prescriptions, over-the-counter meds must be brought in their original container and discussed with the the Youth Pastor. If your student does not have medical insurance please type NONE.