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Hmong Mission Society LCMS
                    LCMS Hmong Ministry Conference
                            Our Savior Lutheran Church
                     7910 E. St. Joe Hwy. Lansing, Michigan 48758
                                    July 19-21, 2012

                       Luke 3:4 “Prepare the Way for the Lord”

                                   Registration Form

Church: ______________________________________________________________

All conference participants must complete a registration form. Incomplete registrations
will be returned and will delay individual or group confirmation to the Conference.

Please print legibly or type. (Check One) ________Adult             ________Youth

Name                         _______________________________________________
Mailing address              _______________________________________________
City                         __________________State         Zip code __________
Phone                                                Cell: ___________________
Email                        _______________________________________________

If any child will be attending the conference, please list name and age of Child (ren)
below. _________________________________________________________________
_______________________________________________________________________

Allergies and Other Known Health Risks/Problems: _____________________________
_______________________________________________________________________
Medications: _______________________________________________________________
Person to Contact in the Event of an Emergency (Name, Address, Telephone Number(s),
Relationship): ____________________________________________________________
Health Insurance Carrier/Policy Number: ______________________________________
__________________________________________________________________________

Youth Information (6th grade and above)

Grade: ________________________________________________________________
College: _______________________________________________________________
Graduate: Yes or No
       Degree: _________________________________________________________


                                            1
ACKNOWLEDGMENT AND RELEASE

I understand that to become a Participant, at the LCMS Hmong Ministry
Conference requires me to acknowledge and agree that the LCMS Hmong Ministry
Conference assumes no, and disclaims all, responsibility for my safety and well-
being while acting as a Participant. In consideration of the LCMS Hmong Ministry
Conference permitting me to be a Participant:

        (a)    I acknowledge that the information set forth above is complete and
accurate;

        (b)    I acknowledge and agree that the LCMS Hmong Ministry Conference is
an auxiliary agency of The Hmong Mission Society and cannot and does not accept any
(and expressly disclaims all) responsibility for my safety and well-being while being a
Participant;

        (c)    I release the LCMS Hmong Ministry Conference, its directors, officers,
employees and agents from all claims, demands, actions or causes of action that I may
have, now or in the future, relating to or resulting from any illness or injuries (including
death) suffered by me or my possessions while being a Participant; and

         (d)     I consent to any medical treatment that the LCMS Hmong Ministry
Conference (or any of its authorized representatives) deems to be necessary or
appropriate in the event of my illness, accident or other medical emergency, and I accept
full financial responsibility for any fees or expenses relating to this treatment.


SIGNATURE: __________________________________ DATE:__________________
PARENT SIGNATURE: ___________________________________________________
(If under 18 years of age)


                       Deadline for registration is June 30, 2012.

          Send ALL Registration Forms and Make $10.00 Check Payable to:
                       LCMS Hmong Ministry Conference
                             Attention: Rev. Chia Thao
                                  2220 E. College Avenue
                                    Appleton, WI 54915




                                             2

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Registration form 2012v2

  • 1. Hmong Mission Society LCMS LCMS Hmong Ministry Conference Our Savior Lutheran Church 7910 E. St. Joe Hwy. Lansing, Michigan 48758 July 19-21, 2012 Luke 3:4 “Prepare the Way for the Lord” Registration Form Church: ______________________________________________________________ All conference participants must complete a registration form. Incomplete registrations will be returned and will delay individual or group confirmation to the Conference. Please print legibly or type. (Check One) ________Adult ________Youth Name _______________________________________________ Mailing address _______________________________________________ City __________________State Zip code __________ Phone Cell: ___________________ Email _______________________________________________ If any child will be attending the conference, please list name and age of Child (ren) below. _________________________________________________________________ _______________________________________________________________________ Allergies and Other Known Health Risks/Problems: _____________________________ _______________________________________________________________________ Medications: _______________________________________________________________ Person to Contact in the Event of an Emergency (Name, Address, Telephone Number(s), Relationship): ____________________________________________________________ Health Insurance Carrier/Policy Number: ______________________________________ __________________________________________________________________________ Youth Information (6th grade and above) Grade: ________________________________________________________________ College: _______________________________________________________________ Graduate: Yes or No Degree: _________________________________________________________ 1
  • 2. ACKNOWLEDGMENT AND RELEASE I understand that to become a Participant, at the LCMS Hmong Ministry Conference requires me to acknowledge and agree that the LCMS Hmong Ministry Conference assumes no, and disclaims all, responsibility for my safety and well- being while acting as a Participant. In consideration of the LCMS Hmong Ministry Conference permitting me to be a Participant: (a) I acknowledge that the information set forth above is complete and accurate; (b) I acknowledge and agree that the LCMS Hmong Ministry Conference is an auxiliary agency of The Hmong Mission Society and cannot and does not accept any (and expressly disclaims all) responsibility for my safety and well-being while being a Participant; (c) I release the LCMS Hmong Ministry Conference, its directors, officers, employees and agents from all claims, demands, actions or causes of action that I may have, now or in the future, relating to or resulting from any illness or injuries (including death) suffered by me or my possessions while being a Participant; and (d) I consent to any medical treatment that the LCMS Hmong Ministry Conference (or any of its authorized representatives) deems to be necessary or appropriate in the event of my illness, accident or other medical emergency, and I accept full financial responsibility for any fees or expenses relating to this treatment. SIGNATURE: __________________________________ DATE:__________________ PARENT SIGNATURE: ___________________________________________________ (If under 18 years of age) Deadline for registration is June 30, 2012. Send ALL Registration Forms and Make $10.00 Check Payable to: LCMS Hmong Ministry Conference Attention: Rev. Chia Thao 2220 E. College Avenue Appleton, WI 54915 2