WEE K Senior High Local Mission Trip Lighthouse Student Ministry Presents July 20 th -24 th 8:00 am – 8:00 pm Daily Medical Release Form I the undersigned (if Student is 18 years of age or older) or parent/guardian of the above listed student acknowledge and fully understand that each Student will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue Lighthouse Community Church, Lighthouse Community Church Student Ministries, its Pastors, Employees, Volunteers or attendees of any of its programs, from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the student’s participation in the programs and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. I hereby give my consent to have a Lighthouse Community Church Staff, volunteer and/or doctor of medicine or dentistry or associated personnel to provide the student with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasee from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasee because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasee. I have read the above waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I understand that this document may not be altered in any manner and that any alteration without the express written consent from the Lighthouse Community Church will cause the participant to be removed from the Program. (Revised 12/05/2013) Parent/Guardian Signature: _________________________________________ Date____________

Participant/ Student Agreement: I, as the participant, understand that while in the attendance of all Lighthouse Community Church events/activities, am under the direction and authority of those leaders in charge. I also understand that the use of alcoholic beverages, illegal drugs, tobacco, fireworks, foul language, abusive and lewd behavior is prohibited as are weapons/dangerous items. These things are grounds for dismissal. I am expected, as a participant, to be with the group at all times. Any variance in the rules and/or events/activities may result in immediate expulsion by asking my parents/guardians to pick me up at their cost. I understand that this is a Christian event/ Activity and will have a spiritual emphasis. Participant/Student Signature: ________________________________________ Date:_________ Registration Forms and$50 due by Sunday July 19 th Please RSVP to Neil or April ASAP Student Name__________________________________ Parent Name___________________________________ Parent Cell_____________________________________ Insurance Company_________________________________ Policy #__________________________________ Med Notes/Meds _______________________________ Rx Meds/OTC Checked in upon Registration $50 Registration Fee Included (circle) Y or N Meals from the Heartland Food Pantry Serving Community Hope Ministries Back Yard Clubs Amanda the Panda Prayer Walks Building Community Lighthouse Student Ministry Presents Local Week July 20th - 24 th A Senior High Local Missions Wee k where we serve the community in many ways, while learning more about the importance of helping those in need. We will be meeting every morning at the church at 8:00 am and finishing at approximately 8:00 pm each night at the church. Registration and the $50 fee is due Sunday, July 19th.