Please complete and submit this Annual Registration form to participate in the Disciples Unlimited BEFORE you attend your first event of the year. Step 1 of 4 25% Student InformationFull Name(Required) First Last Student's Email(Required) Enter Email Confirm Email Cell Phone(Required)Address(Required) Street Address Address Line 2 City State Zip Age(Required) Birth Date(Required) Month Day Year School Grade(Required) Parent/Guardian 1Name 1 First Last Relationship to Student 1 Email 1 Cell Phone 1Employer 1 Work Phone 1Parent/Guardian 2Name 2 First Last Relationship to Student 2 Email 2 Cell Phone 2Employer 2 Work Phone 2 Other Information About Your ChildPlease list below any other important information about your student and your family you feel we should know (learning difficulties, behavioral issues, custody issues, etc.). All information is kept confidential and is for understanding situations and behaviors as they arise.Additional Important Information:Insurance InformationHealth Plan Carrier(Required) Policy #(Required) Policy Holder's Name(Required) Emergency Contact InformationEmergency Contact Name(Required) First Last Relationship to Student(Required) Emergency Contact Home PhoneEmergency Contact Cell Phone(Required)Student's Medical InformationPlease list medical conditions, allergies, etc.Please list required medications Parent Consent to Treat a MinorI, being the parent or legal guardian, do consent to any x-ray, anesthetic, medical, surgical, or dental diagnosis or treatment that may be deemed necessary for my minor child. Further, I understand that all efforts will be made to contact me prior to treatment. In the event I cannot be reached in an emergency, I give permission to the adult supervisor to make the decisions necessary for treatment. Should there be no adult supervisor available, I give permission to the attending physician to treat my minor child. I further understand that the doctors, dentists and other providers attending to my child will take all reasonable safety precautions during their care. Further, as parent or legal guardian, I am responsible for the health care decisions for my minor child and agree that my insurance plan is the primary plan to pay for the dental, medical, or hospital care or treatment that is given to my child. Any policy of the church or organization sponsoring the events will be used as the secondary coverage.Parent/Guardian Printed Name(Required) First Last Parent/Guardian Signature(Required) First Last By completing this section, it indicates that you legally signed this document in agreement.Date Signed by Parent/Guardian(Required) Month Day Year Topic Night for Teens Registration“Topic Night for Teens” (TNT) is our senior youth (9th-12th grade) ministry nights that exist for youth to form community with fellow youth and adult mentors in a Christian context, as they grow in their faith in Jesus Christ. “TNT” meets Wednesday evenings from approximately 6:00 – 7:30 PM. Please be aware we sometimes take youth to the nearby Starbucks or McDonalds as a special treat for part of the evening. Minors are not permitted to drive other minors for Peace Student Ministry activities.Will your youth participate in Topic Night for Teens (TNT)(Required) Yes No Activity Participation AgreementsI, being the parent or legal guardian, have been informed of the High School Calendar HERE ("the activities") sponsored by Peace Lutheran Church ("PLC") and hereby give my consent for my minor child to participate in these activities. In consideration for the opportunity to anticipate in the activities, the Participant (parent/guardian if Participant is a minor) acknowledges and accepts risks of injury associated with participation in and transportation to and from the activities. The Participant (or aren't/guardian) accepts personal financial responsibility for any injury sustained during the activities or during transportation to and from the activities. Further, the Participant (or parent/guardian) promises to indemnify, defend, and hold harmless the activity sponsor or its agents, employees, volunteers, or any other representatives of PLC for any injury related directly or indirectly out of the described activities or transportation to and from the activities, whether such injury arises out of the negligence of PLC or otherwise. If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and PLC cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel of the American Arbitration Association for final resolution.Please check the statements below as your acknowledgment.(Required) I have read and understand the above Activity Participation Agreements. My child may participate in PLC sponsored activities at Peace Lutheran Church or those listed above. Select AllEarly Return Consent StatementIn the event a student must return from an PLC sponsored event independently for reasons of health, accident or failure to conform to rules established by the adult leaders, event supervisors, etc., the parent/guardian agrees to accept full responsibility for and pay for the cost of medical care, transportation and other related incidental expenses.Please check the statement below as your acknowledgment.(Required) I agree to the "Early Return Consent Statement" Terms. Student AgreementI, the above-named student, as a participant in student events sponsored by PLC, will listen to my adult leaders and event supervisors. will abide by all guidelines especially instructions related to my safety and the safety of my fellow students. I understand that failure to follow the prescribed guidelines and/or safety procedures may result in my having to leave an PLC sponsored event early and at my parent/guardians expense. I understand that injury to myself, or a fellow student may also result from my failure to comply with safety procedures. I have read the above paragraph and understand its significance related to my participation in PLC sponsored events. I also understand that this agreement is important because I want all of our students to have an amazing, positive and uplifting experience while attending PLC sponsored youth events.Student Signature(Required) First Last By completing this section, it indicates that you legally signed this document in agreement.Date Signed by Student(Required) Month Day Year CAPTCHA*** After submitting this completed form, please submit a front and back copy of your insurance card to the church office.NameThis field is for validation purposes and should be left unchanged.