2024 Regional Lock In

2024 Mid-America Disciples

Regional Lock In
Registration and Health History

6th-12th Grade

January 13 & 14

You will need to fill out a form for each youth you are sending.

Participant Name*

Gender *

Age*

Grade (2023 2024 school year)*

YR of HS Graduation*

T Shirt Size*

Participant Address*

Participant Address

Street Address Line 2

City/State/Zip

Every Church Participating must send 1 Sponsor for every 5 Youth attending.If a participant wants to come but is the only one coing from that particpant's church email Zane Whorton at zanew78@gmail.com to be paired with a church that is sending a sponsor. _________________________________________Youth Sponsor Name*

Local Congregation & City*

Church or Pastor's or Youth Pastor's Email Address*

example@example.com

Parent/Guardian's Name*

E mail*

example@example.com

Cell Phone*

Other Phone*

Secondary Parent/Guardian's Name

E mail

example@example.com

Cell Phone

Other Phone

If Parents/Guardians are unavailable in emergency, notify (name)*

Relationship to Participant*

Primary Phone*

Other Phone

Initial Below:We/l authorize staff to administer over the counter medication to my child for minor pain, headache, upset stomach, sore throat, cold *

Initial Below: We/I give permission for our/my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Mid-America Disciples (DOC) Summer Ministry. *

Initials Below indicate that We/l give permission for our/my child to be photographed, video or audio taped and understand that these photos, videos, or recordings may be used of the Christian Church (DOC) newsletters, promotion or other print, digital or internet publications. Campers names will NOT be posted or tagged in social media posts.*

Initials Below indicate that We/l give permission for our/my child to have emergency medical treatment decisions made by the the local congregation. Our intials alos indicate that they have been given pertinent physical and emotinal information needed*

Signature of Custodial Parent/Guardian (or Adult Camper/Staff)*

Printed Name*

Date*

Date

Participant Covenant: I covenant with my Creator, event staff, and other participants to do my best to: Expect the best of others, and give my best in our activities together. Participate fully in activities and attend the entire event. Abide by rules, policies, and expectations of the camp/event. Expect to make new friends, be a friend to others, and have fun. Respect event property and personal belongings of participants and staff.

Respect each person's dignity, affirming that each one is created VERY GOOD, in the image of God. Be a good steward of creation, appreciating and caring for the environment. Grow in my relationship with Jesus Christ, through prayer, Bible study, worship and fellowship. Create a community of hospitality and inclusion that honors the unique contributions of each person.

Camper Signature*

Printed Name*

Date*

Date