Beautiful Savior
Colorado Camp Week
Where are we going?
Lutheran Valley Retreat (LVR) - Colorado
Who can go?
7th-12th grade students who fill out registration and pay the deposit
When are we going?
June 6-14, 2014.
How much will it cost?
The cost of the trip will be $400 per person.
What will the cost include?
The cost includes camp registration, food, lodging, servant event, camp programming, and transportation to and from
Lutheran Valley Retreat in Colorado. Meals to and from LVR are not covered and any souvenirs students will want are
extra. The first meal covered is breakfast on Saturday the 7th; the last meal covered is breakfast on Saturday the 14th.
What will we be doing?
Our group will partner with Lutheran Valley Retreat for 2 days to conduct local service projects in and around camp.
You’ll learn new skills, serve in important roles, and have loads of fun as you: help camp and the surrounding
communities with projects including Pike National Forest improvements, camp improvements, building projects, and
more. You will some experience some super highs and some lows while rock climbing/rebelling, ropes course,
backpacking, white water rafting, sunrise hike, and much more as you grow in your relationship with Jesus.
What will a typical day look like?
A "typical" day involves serving others, session time, daily devotions, and inspirational/interactive worship.
Monday-Friday
7:30 a.m. Breakfast
8:30 a.m. Worship
9:00 a.m. Session time
12:00 p.m. Lunch
1:15 p.m. Session time
3:30 p.m. Hospitality tasks and free time
5:30 p.m. Dinner
7:30 p.m. Evening activities
How do I register for the trip?
To register for the trip, please complete the attached form along with your $100 nonrefundable deposit to the church
office. Registrations are due ASAP!
When is my money due?
$100 deposits are due Feb. 2nd!
$150 Trip payment 1 is due on March 16th, 2014
$150 Trip payment 2 (final payment) is due on May 18th, 2014 *
*These payment due dates are few days in advance of our payment due to Lutheran Valley Retreat.
Who is leading?
We have a very capable and responsible group of adults going this year. Josh Keithley will be leading the group along
with the rest of the Student Ministry staff. There will be 2 college students from Nebraska Christian College and more
adult mentors from Beautiful Savior. Each have submitted background checks and have a passion for youth ministry.
Josh, Scotte, and Sergio will be teaching, NCC students will lead us in worship, games, and devotions, and our adults will
help with driving, small group leaders, and walk along side our students as they experience a life changing week at camp.
What will we eat?
A total of 22 meals will be provided during the trip, beginning with breakfast on Saturday morning the 7th. Meals will
consist of traditional breakfasts, lunches, and hot dinners. Participants take turns preparing and cleaning up. The last
meal will be breakfast on Saturday morning the 14th. There is a camp store with souvenirs and snacks that will be open in
the afternoon each day.
Where are we staying?
We will be sleeping in cabins where each student and adult will have a bed. Accommodations will include areas for
groups to room together by gender, a common eating area, and a program area. Plan to sleep on bunk beds (so bring
single size sheets and/or sleeping bags). Showers will be available for both male and females.
PLEASE, make sure everyone brings a swimming suit to be prepared for any showering situation.
What should my student bring?
We will provide an itemized packing list of what to bring as we get closer.
What should my student not bring?
Please go through your students gear before they come and help them make these decisions. I am always asked about
cell phones. If your student has a phone, it is ok to bring. They will be asked not to use it during our servant event times
or sessions. We do occasionally temporarily hold on to phones to help our students focus during the trip if needed. We
will be in the mountains and it is a 99% chance there will be no cell phone service.
What if I need to cancel?
We will do our best to work with you if cancelling for a family emergency. For all other reasons even if a trip is cancelled,
full payment for the trip is still due. If you find your own same gender replacement, associated costs could be
transferred within those families. We contract with an outside ministry to help us make arrangements for this trip. We
schedule our payments for when our payment is due to camp. Forfeiture of payments is not us being cantankerous; it is
because we have forfeited our own payment as well.
If you would like more information on the ministry that helps us plan and carry out our Discipleship Year 2 Retreat,
please visit www.lvr.org .
It is our prayer that this experience will move your student to grow spiritually in a way that is life changing.
Key Dates
Feb 2nd- Deposit due ($100)
March 16th- 1st payment due ($150)
May 18th- 2nd payment due ($150)
June 1st - Final meeting 12:30 PM Student Center
Josh Keithley
Director of High School Ministry
Beautiful Savior Lutheran Church – 7706 S 96th St – LaVista, NE - 68128 – 402.331.7376
Medical Information, Consent, and Release of Liability Form
_____________________________
Last name of minor participant
_________________________ ____
First name
____ Male
____ Female
____
Age
_______________
Date of Birth
______
Grade
____
MI
(____)______________
Home phone of guardian
________________________
Social Security Number
_____________________________
Parent/Guardian Name
__________________________
Street address
______________
City
____
State
_______
Zip
_____________________________
Name – alternate adult contact
__________________________
Relationship to participant
(____)_________ (_____)_________
Phone – Day
Evening
Emergency and Health information Please indicate anything you would want a medical professional to know regarding your child.
Does the following minor participant have… (if yes, please explain)
____yes ____no
Allergies? _____________________________________________________________________________
____yes ____no
Heart condition? ________________________________________________________________________
____yes ____no
other? ________________________________________________________________________________
Is the following minor participant subject to…(if yes, please explain)
____yes ____no
Fainting? ______________________________________________________________________________
____yes ____no
Sleep walking? _________________________________________________________________________
____yes ____no
Upset stomach? _________________________________________________________________________
____yes ____no
Motion sickness? _______________________________________________________________________
____yes ____no
other? ________________________________________________________________________________
Does the following minor participant have a negative reaction to…(if yes, please explain)
____yes ____no
Bee sting? _____________________________________________________________________________
____yes ____no
Penicillin? _____________________________________________________________________________
____yes ____no
other drugs? ___________________________________________________________________________
____yes ____no
Poison ivy, oak, sumac? __________________________________________________________________
____yes ____no
other? ________________________________________________________________________________
Please indicate anything else leaders should know about to help in ensure that your minor participant has a positive
experience.__________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date of last tetanus shot_________________
Insurance Co.____________________________________
Policy #_______________________________________
Name of policy holder______________________________________________________________________________
Does your health insurance require pre-certification? ____yes ____no If yes, phone number (____) _______________
Name of Doctor ____________________________
Phone (____) ____________________
The staff and youth leaders of Beautiful Savior Lutheran Church have my permission to give my minor participant:
____yes ____no Robitussin (cough medication) ____yes ____no motion sickness medication (Dramamine etc.)
____yes ____no acetaminophen (Tylenol)
____yes ____no antacid (Rolaids/Mylanta/Tums etc.)
____yes ____no diphenhydramine (Benadryl)
____yes ____no ibuprofen (Advil etc.)
____yes ____no topical antibiotic ointment
____yes ____no topical cortisone (Cortaid etc.)
____yes ____no Pepto-Bismol, or Kaopectate
____yes ____no skin ointment//treatment (SolarCaine, Chapstick, etc.)
____yes ____no cold medications (Dayquil, etc) ____yes ____no gynecological medications (Midol etc.)
____yes ____no topical antiseptic (Betadine etc) ____yes ____no Calamine/Caladryl
____yes ____no naproxen sodium (Aleve etc.)
____yes ____no other (please specify)
Please list any medications your minor participant is taking on a regular basis or will be taking during this experience, including
vitamins and/or nutrition supplements:_____________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Emergency Procedure: In the event of any emergency, the adult staff and youth leaders will attempt to first contact the
parent/guardian of your minor participant. If this is not possible or if there is insufficient time to make such contact please
note below:
With my signature below,
 I authorize first aid administered by staff and adult leaders of Beautiful Savior Lutheran Church.
 I authorize emergency medical and dental care by hospital staff and or doctor selected by Beautiful Savior Lutheran Church
staff or adult leaders and will pay all costs associated with such care.
 I authorize the doctor selected by Beautiful Savior Lutheran Church staff or adult leaders to hospitalize, secure treatment for,
and to order injection, anesthesia, blood transfusion or surgery. A plastic surgeon will be asked for any facial or neck injuries.
 I authorize said minor participant to ride in vehicles designated by staff and adult leaders of Beautiful Savior Lutheran
Church while attending and participating in activities sponsored by Beautiful Savior Lutheran Church
 I authorize Beautiful Savior Lutheran Church to use my minor participant’s voice and/or likeness in video, still photography,
internet projects, or other means, in the various ministries of Beautiful Savior Lutheran Church.
 I understand that if it should become necessary for my minor participant to return home due to medical, behavioral, or other
reasons, I will assume all costs associated with transporting my minor participant.
I hereby consent to participation of my child (or myself) in the:
Colorado Camp Week June 6-14, 2014
I understand that I have a duty to provide primary accident and medical insurance for my child (or myself) and I declare that my child
is (or I am) covered by primary accident and medical insurance.
I release and forever discharge The Lutheran Church – Missouri Synod and Beautiful Savior Lutheran Church, Omaha Nebraska,
their agents and servants, successors and assigns, directors, trustees, officers, employees, and other representatives from any and all
damages and causes of action either at law or in equity that I may have as a result of my child’s (or my) participation in, attendance
at, and travel to and from the trip.
Furthermore, I do hereby expressly stipulate, and agree to indemnify and hold forever harmless The Lutheran Church – Missouri
Synod and Beautiful Savior Lutheran Church, Omaha Nebraska, its agents and servants, successors and assigns, directors, trustees,
officers, employees, and other representatives against loss from any and all present or future claims, demands or actions in law or in
equity that may hereafter be made or brought by me or my child, by anyone on behalf of my child or me, or by anyone else on their
own behalf for damages or any other legal or equitable remedy on account of any injury, illness, physical condition, inconvenience or
loss sustained by my child or me during the trip or travel to and from the same.
I, the undersigned, hereby acknowledge that I have read the foregoing, understand its contents, and have signed the same as my own
free act and deed.
FOR PARTICPANTS AGE 21 AND OVER:
__________________________
Participant Signature
_______________
Date
________________________
Witness
FOR PARTICPANTS UNDER AGE 21:
_______________________
Parent/Guardian signature
_______________________
Parent/Guardian signature
______________________
Minor participant signature