2016 HS FALL YOUTH RETREAT SIGN UP 2016 High School Fall Youth Retreat Sign Up Student #1Student #1 Full NameBirth Date GenderMaleFemaleCell PhoneEmail Address School in the FallAdult T-Shirt SizeSmallMediumLargeXLI wish to ride the late van:YesNoIt is important for us to meet the needs of all of our children. Does your child have any allergies or special needs, etc?NoYesPlease explain:Student #2Student #2 Full NameBirth Date GenderMaleFemaleCell PhoneEmail Address Adult T-Shirt SizeSmallMediumLargeXLSchool in the FallI wish to ride the late van:YesNoIt is important for us to meet the needs of all of our children. Does your child have any allergies or special needs, etc?NoYesPlease explain:Household / Adult Primary ContactRelationship to Participants*MotherFatherGuardianOtherFirst Name*Last Name*Relationship to ParticipantsAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Terms & Conditions* I Agree 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 June 1, 2016 to June 1, 2017.EmailThis field is for validation purposes and should be left unchanged.