Trinity Lutheran Church of Fort Pierce

Youth Lock-in Permission Slip

Parent/Guardian Basic Information

Parent/Guardian Name(Required)

First Last

Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Phone(Required)

Email(Required)

Youth Basic Information

Youth Name(Required)

First Last

Date of Birth

Age(Required)

Please enter a number from 10 to 17.

Grade in School(Required)

Youth Address(Required)

Same as Parent/Guardian

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact

Name(Required)

First Last

Phone(Required)

Relationship with Youth(Required)

Medical Information

Physician's Name

First Last

Physician's Phone Number

Youth Allegies or Medications:(Required)

Things to Bring

1. Sleeping bag/blanket 2. Pillow 3. Pajamas, socks/slippers 4. Personal items (toothbrush, toothpaste, brush, deodorant etc.) 5. Black/dark clothing (long sleeve top and long pants) 6. Special medication or required items (indicate on the permission form).

Lock-in Rules

1. All youth must sign this sheet, indicating their agreement to these rules. 2. No one is allowed to attend the lock-in without a signed parental permission slip and contact numbers. 3. Lock-in participants will not be allowed to go outside of church or venue without adult supervision. No unauthorized entering or exiting. 4. No insults or sarcasm: We do not put others down, make fun of others (especially those who arenʼt with us), pick on others, or gossip about. 5. Use your body respectfully: No revealing clothing, no PDA, no chasing, throwing, or hurting others. 6. Keep it clean: no swearing 7. NO personal video games. Tablets/cell phones will remain put up for the majority of the evening. 8. Special medication or required items should be indicated on the permission form and given to the chaperones. 9. All lock-in participants must respect othersʼ physical boundaries. 10. Same sex sleeping quarters will be provided (for those who wish to sleep). Lights out/quiet hours will be observed in these areas. 11. It is expected that all lock-in participants (youth and adults) will participate in the activities. 12. Take care of yourself and clean up after yourself. 13. Be considerate and respectful of other participants and leaders. 14. Be respectful of the church and property of the church. By signing this permission slip, I understand the following: • Lock-in is designed for youth grades 6-12. • Parents must provide a phone number where they can be reached during the evening in case of emergency. • Parents will be called to pick up their teen if the teen leaves the building for any length of time and/or acts in a manner deemed unacceptable by the Youth Ministries Leaders and/or Chaperones. • Participants should stay home if they are showing signs of communicable illness

Click here to indicate that you and your youth have read the lock-in rules.(Required)

Click to sign.

By clicking above, I understand the following:
• Lock-in is designed for youth grades 6-12.
• Parents must provide a phone number where they can be reached during the evening in case
of emergency.
• Parents will be called to pick up their teen if the teen leaves the building for any length of time
and/or acts in a manner deemed unacceptable by the Youth Ministries Leaders and/or
Chaperones.
• Participants should stay home if they are showing signs of communicable illness

Medical and Liability Release(Required)

Click to sign.

I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for
the said child to attend and participate in the events and activities of the Trinity Lutheran Church Youth Lock-in
scheduled for Friday, Feb. 24th, at 7:00pm to Saturday, Feb. 25th, at 7:00am
Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in
charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and

any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-
being of the child affected; (3) I cannot be personally contacted.

I further agree not to hold Trinity Lutheran Church or any of its paid staff or volunteers responsible for any accident
that may occur on the way to, from, or during the event. I indemnify, defend and hold harmless Trinity Lutheran
Church for all claims made and liabilities assessed against them as a result of any event or activity. I release Trinity
Lutheran Church and all medical providers from liability in acting on my behalf in this regard and rendering such
medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity.
Furthermore, I understand and assume the expenses of any property damage caused by my child. Should it be
necessary that my child be returned home due to disciplinary action, I will be contacted by the leaders and will be
responsible to pick my child up.
By clicking above, I am acknowledging that I have read through and understand the above statements.

Date(Required)