Road Trip With Jesus

Oregon Trail Road Trip With Jesus
July 6th -July 11th
Cost Per Student : $200.00
Students going into High School through 12th Grade.
Deadline to Register : June 15th

Registration Form

* Indicates required field

Full Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Grade In School *

Birthdate *

Church *

For Your Parents

Parent/ Guardian Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Church *

Day Phone Number *

Night Phone Number *

Cell Phone Number *

In Case of Emergency Name *

First

Last

Emergency Contact Address *

Line 1

Line 2

City

State

Zip Code

Country

Day Phone Number *

Cell Phone Number *

Relationship to Child *

I can provide snacks? Yes or No *

I can chaperone the trip. Yes or No *

Type of Medical Concern *

Medical Insurance Carrier *

Policy Holder Name *

Policy Holder Phone Number *

Policy Holder ID/Policy Number *

Dental Provider Phone Number *

Dental Provider ID/Policy Number *

I hereby give informed and expressed consent for my child to take part in all road trip activities under supervision, and agree that West Linn Lutheran will not be held responsible for accidents arising there from. I authorize West Linn Lutheran Church to provide appropriate treatment to my child for injuries and/or illness. I understand that the information on this form may be released to the appropriate medical personnel in case of medical emergency. Lastly, I verify that everything contained on this form is complete and accurate, to the best of my knowledge. *

I consent.

I also consent to the use of any photograph of my child or family in any West Linn Lutheran Church publications. *

I consent.

Submit

You can also download the registration form below and return to :
West Linn Lutheran Church
20390 Willamette Drive
West Linn Oregon 97068.

Oregon Trail Road Trip With JesusJuly 6th -July 11thCost Per Student : $200.00Students going into High School through 12th Grade. Deadline to Register : June 15th

Registration Form

Oregon Trail Road Trip With Jesus
July 6th -July 11th
Cost Per Student : $200.00
Students going into High School through 12th Grade.
Deadline to Register : June 15th