2018 HIGH SCHOOL FALL YOUTH RETREAT

at beautiful CRAN-HILL RANCH near Rodney, Michigan

Friday, October 5, 7pm* to

Sunday, October 7, 2pm

* Late vans will leave from CMC at 10pm. Priority will be given to players and cheerleaders.

COST: $40

Tie-Dying ~ Capture the Flag ~ Bonfires & Hobo Pies ~ Polar-Bearing ~ Ga-ga Ball

FRIENDS ARE WELCOME!

Meet at CMC’s Youth Center (Entrance F)

Registration Deadline: Sunday, September 30, 10pm

Once we have received your registration form, you will receive a confirmation email with instructions on how to pay. Once you have paid, your form will be complete!

No registration will be accepted without payment.

Student #1 Full Name *

Birth Date * +

Gender *

Grade *

Student Cell Phone # *

Student Email Address *

School in the Fall *

Adult T-Shirt Size *

I wish to ride the late van: *

It is important for us to meet the needs of all of our children. Does your child have any allergies or special needs, etc? *

Yes

If you marked yes, please explain:

Student #2 Full Name

Birth Date +

Gender

Grade

Student Cell Phone #

Student Email Address

School in the Fall

Adult T-Shirt Size

I wish to ride the late van:

It is important for us to meet the needs of all of our children. Does your child have any allergies or special needs, etc?

Yes

If you marked yes, please explain:

In checking YES, I AGREE on this document, I hereby certify that the ALL of the enclosed information is correct. In the event that I cannot be reached, I hereby give permission to the physician selected by the CMC staff to obtain proper medical diagnosis, hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child as named above.

I also acknowledge I have read, understand and accept the terms listed below:

RELEASE OF LIABILITY

The PARTICIPANT, their PARENTS, GUARDIANS, HEIRS, ASSIGNS and REPRESENTATIVES hereby release Christ Memorial Reformed Church, its staff members, volunteers, agents and representatives of any and all liability for any loss, injury, or property damage which may be the result of any aspect of any mission trip, retreat, event, excursion or regular programming/classes including transportation to/from these activities. The Participant may participate in activities as mentioned above located both on and off CMC property for the duration of this release. The Participant and the Participant's Parent(s) and/or Guardian(s) understand, acknowledge and accept that there are inherent risks, both known and unknown, in travel and in the activities in which the participant will engage in during mission trip, retreat, event, excursion or regular programming/classes.

The Participant and the Participant's Parent(s) and/or Guardians also understand and acknowledge that individual Participants are not covered under any policy of insurance held by Christ Memorial Reformed Church and that Participants must provide any and all insurance coverage for themselves, including, but not limited to health, life and liability insurance.

Photographs or videos may be taken during the experience of the mission trip, retreat, event, excursion, or regular programming/classes you or your child will be participating in. By signing this form, you are authorizing Christ Memorial Church to use those videos and/or photographs in any manner deemed appropriate by Christ Memorial Church, including, but not limited to use in promotional materials or church services.

This release is valid from September 1, 2018 to Semptember 1, 2019.

Yes - I agree

Parent/Guardian Signature *

Date *

Household / Adult Primary Contact

Relationship to Participants: *

Mother

Father

Guardian

Other Other

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Parent Phone # *

Email Address *

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