Youth Midwinter Retreat 2025 Adult Registration Step 1 of 3 33% Adult Participant InformationParticipant Name(Required) First Last Preferred Name Gender Identity(Required) Participant Birth Date(Required) Month Day Year Participant Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant Email(Required) Preferred Phone Number(Required)Participant Shirt Size(Required)(Adult Sizes Only)SMLXL2XL3XLChurch Attending With:(Required) Emergency Contact InformationName of person to contact in case of emergency:Emergency Contact Name(Required) First Last Emergency Contact Relationship to Participant(Required) Emergency Contact Phone(Required)Emergency Contact Email(Required) Medical InformationAllergies/Dietary RestrictionsPlease specifyMedicationsPlease list all medications being brought to the retreat, along with the amount and time of day they are to be taken.Insurance InformationHealth Insurance Company(Required) Full Name of Insured(Required) Full Name of Primary Cardholder/Insurance Holder(Required) Birth Date of Primary Cardholder/Insurance Holder(Required) Month Day Year Policy ID Number(Required) Group ID Number (If applicable)Insurance Company Customer Service Phone(Required) Permissions and ReleasesHighland Lakes Camp Release Form(Required) Highland Lakes Camp requires the completion of an additional release form for all camp guests. Please follow this link (will open in a new window) in order to access their release form.Medical Release(Required)I hereby authorize the Capital District of the Rio Texas Conference of the United Methodist Church (“Capital District”) and the adult leaders from its participating churches serving as ministry staff to administer the medications as listed above. In order for me to receive necessary medical treatment from medical staff and/or physicians in a medical clinic or hospital in case of illness or injury, I hereby consent to and authorize the ministry staff to obtain and consent to medical treatment for such illness or injury during the activity or activities of the Capital District in the case that I am not able to give such consent myself. It is understood that this authorization and consent is given in advance of any specific diagnosis or treatment and is given to encourage those persons who have temporary custody of the Participant and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment in the case that I am unable to give such consent. This medical consent will remain effective until January 19, 2025. I understand that any and all medical expenses incurred are my responsibility. I agree. I hereby authorize the Capital District of the Rio Texas Conference of the United Methodist Church (“Capital District”) and the adult leaders from its participating churches serving as ministry staff to administer the medications as listed above. In order for me to receive necessary medical treatment from medical staff and/or physicians in a medical clinic or hospital in case of illness or injury, I hereby consent to and authorize the ministry staff to obtain and consent to medical treatment for such illness or injury during the activity or activities of the Capital District in the case that I am not able to give such consent myself. It is understood that this authorization and consent is given in advance of any specific diagnosis or treatment and is given to encourage those persons who have temporary custody of the Participant and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment in the case that I am unable to give such consent. This medical consent will remain effective until January 19, 2025. I understand that any and all medical expenses incurred are my responsibility.Liability Release(Required)In consideration of the Capital District here allowing me to participate in activities referenced above, I agree to release and hold harmless the Capital District, its officers, agents and/or designated leadership, from any liability to or responsibility for bodily injury, damage, or illness I may experience while participating in any athletic or social activity which may be directly or indirectly sponsored by the Capital District. Further, I agree to indemnify and hold harmless the Capital District, its participating churches, its officers, agents and/or designated leadership with respect to any claim asserted by me as a result of bodily injury, illness, or damage. I agree.Photo/Video Release(Required)I, hereby grant permission to the Capital District and its participating churches to use any still and/or moving image (video footage, photographs, and/or audio footage) depicting me on the district and/or church’s website, social media groups, or other online and/or printed publications without further consideration. I acknowledge the Capital District and its participating churches have the right to alter the photograph(s) at their discretion. I also acknowledge that the Capital District and its participating churches may choose not to use my photograph(s) at this time, but may do so at a later date, up to 2 years from the date of the photograph was taken. I also understand that once an image is posted on the website or other online platform, the image can be downloaded by any computer user, anywhere in the world. The Capital District and its participating churches commit to eliminating any identifying information including name and age from the publication. I hereby waive any right I may have to inspect and/or approve the finished product or the copy wherein my likeness appears, or the use of which it may be applied. I hereby release, discharge, and agree to indemnify and hold harmless the Capital District, its participating churches, its officers, agents and/or designated leadership, from all claims, demands, and causes of action that I have or may have by reason of this authorization or use of my photographic portraits, pictures, digital images, or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including, but not limited to, publication on the internet, in brochures, or any other advertisements or promotional materials. I agree.Consent and Signature(Required)I have read and understand the above releases (Medical Release, Liability Release, Photo/Video Release) and hereby give my written consent. I also agree, to the extent that I sign electronically, that my electronic signature is the legally binding equivalent to my handwritten signature. I have read and understand the above releases (Medical Release, Liability Release, Photo/Video Release) and hereby give my written consent. I also agree, to the extent that I sign electronically, that my electronic signature is the legally binding equivalent to my handwritten signature.Full Name – Electronic Signature(Required) Date(Required) Month Day Year PhoneThis field is for validation purposes and should be left unchanged. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Like this:Like Loading...
