H.O.M.E. Registration 2026

Student Participant Information

Student Participant Name

Student Participant DOB

Student Participant Cell Phone

Student Participant Email

This address will receive a confirmation email

Student Participant Home Address

Parent/Guardian Information

Parent/Guardian #1 Name

Parent/Guardian #1 Cell Phone

Parent/Guardian #1 Email

This address will receive a confirmation email

Parent/Guardian #1 Address

Best way to contact Parent/Guardian #1:

Parent/Guardian #2 Name

Parent/Guardian #2 Cell Phone

Parent/Guardian #2 Email

This address will receive a confirmation email

Parent/Guardian #2 Address

Best way to contact Parent/Guardian #2:

Emergency Contact (other than parent/guardian)

Emergency Contact Name

Emergency Contact Cell Phone

Medical Information, Dietary Restriction, Activity Limitations

Physician Name:

Physician Phone

Insurance Company

Insurance Policy #:

Dentist Name:

Dentist Phone:

Date of last tetanus shot

Will your child require any medication(s) while on the trip? If so, please list medication and dosage:

Allergies (if none, please state that):

Does your child have any dietary restrictions (e.g., gluten free, vegan, vegetarian?). Please describe:

Is your child being treated or suffer from any of the following:

Heart trouble Epilepsy/seizure disorder Frequent headaches Frequent stomach aches Any physical limitations (please specify) Asthma Diabetes

My child is a:

good swimmer fair swimmer non swimmer

Any other medical, behavioral, or general things we ought to know?

Any restricted activities? Please eplain.

Payment

Copy and paste URL to pay online: https://give.tithe.ly/?formId=f0cc1193-baec-46c6-92b4-3b084c41d944

I am paying:

1st Deposit $200 due by 12/5/25 Balance $275 due by 3/8/26 Entire amount $475 I will pay by check

Chaperones

Interested in being a chaperone?

Student Code of Conduct

Students must abide by the following codes of conduct:
* No possession or use of alcohol, drugs or tobacco.
* No student may drive.
* No fighting, weapons, fireworks, lighters or explosives.
* No immodest or offensive clothing.
* No boys in girls' sleeping quarters and no girls in boys' sleeping quarters.
* Participation with the group is expected.
* Respect each other and adult leaders.
* Respect and comply with the event schedules.

** NO CELL PHONES OR OTHER ELECTRONIC DEVICES PERMITTED**

Students who fail to comply with these expectations may be sent home at their family's expense.

By filling in my name below as my electronic signature, I acknowledge that I have read the rules of conduct and I agree to abide by them. I also have read my health evaluation form and agree to abide by any personal limitations listed.

Student Participant Signature and Date

Medical Release, Waiver and Permission to Treat

By filling in my name below as my electronic signature, I acknowledge and agree:

I am the parent or legal guardian/custodian of the Student Participant named above and give my consent for him/her to attend activities organized by St. Andrew's Episcopal Church (the "Church."). I understand that there are inherent risks involved in these activities and release the Church, its clergy and staff, agents and adult leaders from any and all liability for any injury, loss, cost, or damage to person or property that may occur during the course of my Student Participant's involvement, including during transportation. If the Student Participant requires medical attention during the course of the activity, I consent to the adult leaders seeking medical or other attention they deem necessary and release the Church, its clergy and staff, agents and adult leaders from any liability for such actions and consent to any reasonable medical treatment deemed necessary by a medical professional. Further, I acknowledge that: I am ultimately responsible for the cost of any medical care not reimbursed by my health insurance provider; that the health insurance information provided above is accurate as of this date; and that I will promptly notify the activity director if this information changes. Finally, I agree to bring the Student Participant home at my own expense should the Student Participant become ill, or if otherwise deemed necessary by the adult leaders.

Media Release

By filling in my name below as my electronic signature, I agree that the Student Participant may be photographed, videotaped, and/or audiotaped during the Church activities and for those images and recordings to be used in the Church website, emails, or social media channels.

Parent Signature and Date

Please fill in your name as your electronic signature

Date:

H.O.M.E. Registration 2026

Description

Please Fix the Following