2026 MI District Youth Gathering CHAPERONE FORM | St. John Lutheran Church & School

PLEASE COMPLETE THIS FORM FOR CHAPERONE REGISTRATION

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

This form MUST be completed by a person over the age of 18.

Chaperone First Name *

Chaperone Last Name *

Chaperone Email *

Chaperone Cell Phone *

Chaperone Date of Birth *

Emergency Contact Name *

Emergency Contact Phone *

2nd Emergency Contact Name *

2nd Emergency Contact Phone *

Please list any medical conditions or concerns regarding the Chaperone.

Please list all of the Chaperone's allergies (food, medications, environmental, etc.)

Consent and Electronic Signature

By checking this box, I give permission for St. John Lutheran Church & School to use photographs and/or video recordings of me or my child taken during events and activities for promotional purposes. This includes, but is not limited to, use on social media, the church or school website, newsletters, and other digital or print publications. I understand that all media will be used at the sole discretion of St. John Lutheran Church & School, and that I am waiving any rights to compensation or ownership related to the use of these materials. *

By checking the box below, I understand that if neither of my emergency contacts can be reached in the event of a medical emergency, I authorize a representative of St. John Lutheran Church & School to seek medical care for me. I further authorize any medical, surgical, x-ray, laboratory, anesthesia, or other procedures deemed necessary by the attending physician or paramedics to be performed. I waive my right to informed consent for such treatment in the event of an emergency. *

By checking the box below, I agree to release from liability and hold harmless St. John Lutheran Church & School, including its staff, agents, officers, and any individuals acting on its behalf, from any claims, liabilities, or damages that may arise from theft, accident, property damage, injury, or death occurring during participation in any St. John Lutheran Church & School event. This release applies to all activities associated with the event, including but not limited to those listed in this signup. *

By checking this box and submitting this form, I affirm that I am at least eighteen (18) years of age. I confirm that I am legally authorized to provide consent on my own behalf. I understand that by typing my name below, I am providing my electronic signature, which is legally binding. *

Full Name of Chaperone *

Date *

Once you submit this form you will automatically be taken to the payment page.