Youth Midwinter Retreat 2025 Youth Registration Step 1 of 4 25% Youth Participant InformationParticipant Name(Required) First Last Preferred Name Gender Identity(Required) Participant Birth Date(Required) Month Day Year Participant Grade(Required)6789101112Participant Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Participant Shirt Size(Required)(Adult Sizes Only)SMLXL2XL3XLChurch Attending With:(Required) Parent/Guardian InformationParent/Guardian 1 – Name(Required) First Last Parent/Guardian 1 – Relationship to Youth(Required) Parent/Guardian 1 – Phone(Required)Parent/Guardian 1 – Email(Required) Parent/Guardian 2 – Name First Last Parent/Guardian 2 – Relationship to Youth Parent/Guardian 2 – PhoneParent/Guardian 2 – Email Emergency Contact InformationIf Parent(s)/Guardian(s) cannot be contacted, name of additional person to contact in case of emergency:Emergency Contact Name(Required) First Last Emergency Contact Relationship to Youth(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.Permission to Participate(Required)I, the undersigned parent or guardian, do hereby attest that all the information on this form concerning my child (the above named youth “Participant”) is the most current available for my child. I give my permission for the Participant to participate in the activities of the Capital District of the Rio Texas Conference of the United Methodist Church (“Capital District”). This includes all sponsored activities on or off the premises of Highland Lakes Camp, including any and all activities involving travel and/or lodging. This permission shall remain in effect until January 19, 2025 unless terminated in writing. I agree. I, the undersigned parent or guardian, do hereby attest that all the information on this form concerning my child (the above named youth “Participant”) is the most current available for my child. I give my permission for the Participant to participate in the activities of the Capital District of the Rio Texas Conference of the United Methodist Church (“Capital District”). This includes all sponsored activities on or off the premises of Highland Lakes Camp, including any and all activities involving travel and/or lodging. This permission shall remain in effect until January 19, 2025 unless terminated in writing.Medical Release(Required)I hereby authorize the Capital District and the adult leaders from its participating churches serving as ministry staff to administer the medications as listed above. In order for my child 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. 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, in my absence, and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment. 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 and the adult leaders from its participating churches serving as ministry staff to administer the medications as listed above. In order for my child 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. 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, in my absence, and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment. This medical consent will remain effective until January 19, 2025. I understand that any and all medical expenses incurred are my responsibility.Transportation Release(Required)I hereby give my permission for the Participant to be transported in any vehicle designated by any ministry leader designated by the Capital District, and in whose care the Participant has been entrusted while attending and participating in an activity or activities of insert the Capital District. I agree.Liability Release(Required)In consideration of the Capital District here allowing my child 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 to my child while participating in any youth 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 officers, agents and/or designated leadership with respect to any claim asserted by or on behalf of my child 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 my child/dependent 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 child/dependent’s 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 child/dependent’s 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 or my child/dependent have or may have by reason of this authorization or use of my child/dependent’s 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 (Permission to Participate, Medical Release, Transportation 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 (Permission to Participate, Medical Release, Transportation 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.Parent/Guardian Name – Electronic Signature(Required) Date(Required) Month Day Year NameThis field is for validation purposes and should be left unchanged. 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