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MSM Fall Lock-in 2024 on Friday, November 1, 2024 @ 6:00 PM

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16.00
Two things to note:
  1. Saturday morning, all families are invited for breakfast at Brader Way, where you'll get to meet your student's small group leader.
  2. We want students to experience as much of the event as they can. If for some reason your student can't participate in the full event, share about those circumstances below so we can arrange for their late arrival / early pick-up time.
Parent/Guardian First Name (2):
Parent/Guardian Last Name (2):
Parent/Guardian Email (2):
Parent/Guardian Phone (2):
Parent/Guardian address (2): If different from above:
*Approx. how many total family members will join us for breakfast (including this student)? NOTE: If registering multiple students, only add family members once.
*Gender (for sleeping assignments):
*Grade:
*School Attending:
*Does this student attend Blackhawk Community Group?:
If so, which Community Group do they attend?:
If known, who is your student's small group leader?:
Students will spend part of the evening in a small-group "crew." Name up to three friends whose group your student would like to be in, in order of preference (we can't guarantee these requests, but we will do our best).
If needed, share about requested accommodations for an early pick-up, non-overnight stay, etc. (Details helpful.):
Help us plan for dinner - given the following menu options, this student would probably choose...
HEALTH & MEDICAL INFORMATION: We collect this information to care well for your student in the event of medical need or emergency.
*Insurance Company:
*Account & Group #:
List any food allergies or special dietary needs your student has:
List any other allergies (drug, seasonal, animal, or other) your student has:
*Will your student carry an epinephrine auto-injector (e.g., EpiPen, Auvi-Q)?:
If yes, where will the auto-injector be kept?:
*Will your student bring prescription or over-the-counter medications, vitamins, and/or supplements?:
If yes, list all PRESCRIPTION medications your student will take or have available during the event, including dosages and frequency. Indicate “phone call requested” if you prefer to share this information via conversation. (Note: Prescribed medication must be supplied in a labeled container indicating the patient's name, correct dosage, and administration instructions.)
If yes, list all OVER-THE-COUNTER medications, vitamins, and/or supplements your student will take or have available during the event, including dosages and frequency. Indicate “phone call requested” if you prefer to share this information via conversation. (Note: Over-the-counter medications, vitamins, and/or supplements must be labeled with the participant’s name.)
If yes, what is your preference for medication tracking and administration? Students will be allowed to self-administer medication unless you indicate otherwise.
*Parent/Guardian Initials:
*Physical Health: List current or past physical conditions, recent illnesses, or health concerns that could be helpful for program staff to be aware of. Indicate “phone call requested” if you prefer to share this information via conversation. (Note: if your student has a specific medical condition or special consideration that will need monitoring during MSM Lock-In, please email a detailed care plan to msm@blackhawkchurch.org)
*Mental Health: List current or past mental health challenges your student has had that could be helpful for program staff to be aware of (e.g., depression, bipolar disorder, generalized anxiety disorder, history of psychiatric treatment or hospitalization). Indicate “phone call requested” if you prefer to share this information via conversation
Emergency Contact (If parent/guardians are unavailable)
*Emergency Contact Name:
*Emergency Contact Phone:
*Relation to student:
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