Registration - Pinecrest Winter Weekend 2024

Full Name*

First NameLast Name

Pronouns:

(ie: she/her, he/him, they/them, etc)

Date of Birth:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Name*

First NameLast Name

Phone Number*

Email*

example@example.com

Dietary Needs or Restrictions (ie: allergies, intolerances, other needs):

Chronic Medical Conditions that chaperones should be aware of:

Insurance provider, group number, and provider name:

Have you ever attended Pinecrest’s Summer Camp?*

YesNo

If not, which Pinecrester referred you to this event?

Permission for Treatment

To the best of my knowledge the above information is correct.

I hereby give my permission to the physician and/or nurse practitioner to treat, hospitalize and perform any procedure necessary, including but not limited to injections, x–rays, anesthesia or surgery in case of emergency.

It is my understanding, if this medical is for a minor, all efforts will be made to contact a parent/guardian prior to any treatments, or immediately following stabilization of an emergency.

Consent Form must be SIGNED by parent/guardian if applicable to a minor or by a camp participant if age 18 or older.

Signature:*

Name of Signed:*

First NameLast Name

I understand that my/my child’s participation in activities led by Pinecrest Lutheran Leadership Ministries, Inc. “Pinecrest” staff is completely voluntary, including transportation to/from Camp Johnsonburg. I have familiarized myself with the camp activities in which I/my child will be participating. I recognize that certain hazards are inherent to camp events and programs, particularly, but no limited to, the activities of sports, service projects, canoe/kayak, and group building initiatives. I understand that the other activities, particularly, but not limited to, ropes courses, climbing wall, zip line are not part of our program but are on site and off limits to participants. I acknowledge that although Pinecrest has taken safety measures and establishes practices to minimize the risk of injury to participants, Pinecrest cannot ensure no guarantee that the participants, equipment, premise, and/or activities will be free of hazards, accidents or injury. Pinecrest is not responsible for my/my child's property. I further recognize the importance of knowing and abiding by camp rules, regulations, and procedures for the safety of all participants. The undersigned understands and desires to participate or gives permission for my child to participate in the activities noted above. The undersigned does herby assume full risk and agree to hold harmless, release, remit, acquit and forever discharge Pinecrest Lutheran Leadership Ministries, Inc., its staff, faculty, volunteers, facility, agents, successors and assigns, of and from all claims, demands, cause of action, obligations, rights, damages, losses, expenses, costs, joinders or controversies arising out of my/my child’s participation in any program or activity at Pinecrest, Johnsonburg or off-site with Pinecrest staff.

Signature*

Name of Signed:*

First NameLast Name

Pinecrest Winter Weekend 2025

Emergency Contact