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NextGen MS Dunes Trip 

Release and Consent Form

Trip Name: Lake Ann Camp Sand Dunes Trip 

Date: August 13-17, 2026

Medical Release Form

I/we the undersigned, are the parents having legal custody, or the legal guardians of the above named participant, a minor, have given our consent for him/her to attend an offsite activity operated by Faith Lutheran Church, or are of legal consenting age myself. In the event that I/he/she is injured while attending an activity and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is called for, which a physician and/or hospital personnel refuses to administer without my/our consent, I/we hereby authorize Lindsey Hodge, the lead adult of our group, or a member of the Faith Lutheran Church staff to give such consent for us if I/we cannot be reached by telephone at one of the numbers listed below, or because of an emergency, there is not time or opportunity to make a telephone call. In the event it becomes necessary for that person to give consent for us, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent so long as the treatment is administered by or under the supervision of a licensed physician. I/we also acknowledge that I/we will be ultimately responsible for the cost of any medical care should the cost of that care not be reimbursed by the health insurance carrier. Further, I/we affirm that the health insurance information provided below is accurate at this date and will, to the best of my/our knowledge, still be in force for the participant named above at the time of the offsite activity.

Liability Release Form

I/we understand that there are inherent risks involved in any offsite activity, and I/we hereby release Faith Lutheran Church, its staff and volunteer workers from any and all liability due to any injury, loss, or damage to person or property that may occur during the course of my/our involvement with Faith Lutheran Church. During any activity your child may be photographed or videotaped for future promotional materials.

Agreement to Transport Home

I/we the undersigned, are the parents having legal custody, or the legal guardians of the above named student, a minor, have given our consent for him/her to attend an offsite activity operated by Faith Lutheran Church, or are of legal consenting age myself. I/we understand that a member of Faith Lutheran Church’s staff may need to send a participant home as a result of illness or discipline problem. I/we understand if the participant named above is dismissed from an activity, I/he/she will be transported home at my/our expense. Faith Lutheran Church will attempt to contact the parent or guardian to arrange such transportation.

Participation on a Faith Lutheran Church offsite activity is contingent upon compliance with all the polices stated in this form. Please sign below that you have read and agree to the policies.

* If the participant is older than 18 years, no Parent/Guardian signatures are necessary.

** The information on this form shall remain in effect from date of signing waiver until the trip/event dates of August 13-17, 2026 unless sooner revoked in writing and delivered to Faith Lutheran Church.

Today's date: May 12, 2026

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Insurance Information
Name of health insurance company
Health insurance policy number
Phone/address of health insurance company
Name of policy holder
Policy holders phone number
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Information
Last date of tetanus shot

List Allergies

Please describe below if presently under a doctor’s care for treatment and / or medication now or in the last two years.

If participant has a chronic health issue, please contact Lindsey Hodge lhodge@faithtroy.org 1 week prior to the trip.


Medications

Reason for taking Medications

Participantmay take the following over the counter medications or rehydration products:

Tylenol*
No
Yes
Imodium*
No
Yes
Excedrin*
No
Yes
Benadryl*
No
Yes
PeptoBismol*
No
Yes
Pedialyte*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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