Student's Name *

First Name

Last Name

Student's Phone Number *

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2023-2024 School Grade *

9th Grade

10th Grade

11th Grade

12th Grade

Parent/Emergency Phone Number *

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Permission *

I grant permission for my child, a minor, to participate in all Peace Lutheran Church Youth Ministry activities that are held on or off site (examples: virtual small group meetings, community service/mission projects, Feed My People, Action City, Fields of Faith, etc.) during the 2023-2024 program year. I understand that I have a duty to provide primary accident and medical insurance for my child. I assume all responsibility and liability for injury to my child. I release and forever discharge the Lutheran Church-Missouri Synod, Peace Lutheran Church and all of its agents, servants, counselors, successors and assigns, directors, trustees, officers, employees and other representatives from any and all damages and causes of action either at law or in equity which I may have as a result of my child's participation in, attendance at, and travel to and from Peace Activities. I further give Peace Adult Leaders authority to act on my behalf in the event I am not able to be reached by the phone number below and my child requires medical attention. By typing my name, I give the above authorization.

First Name

Last Name