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What is your first name? (the parent or guardian) *

 
What is your last name? *

 
What is the best phone number to reach you at while your student is on this retreat? *

 
One student at a time! What is your student's first name? *

 
What is {{answer_49757534}}'s last name? *

 
What grade will {{answer_49757534}} be in for the 2017-2018 school year? *


 
Is {{answer_49757534}} a boy or a girl? *


 
What is {{answer_49757534}}'s shirt size? (adult) *


 
What is {{answer_49757534}}'s cell phone number? (if they have one)

 
Does {{answer_49757534}} have any food or medical allergies that we should be aware of? *

     
 
Please list all allergies here: *

 
Does {{answer_49757534}} have any physical or mental limitations or issues that will requires special assistance from leaders during the retreat? *

     
 
Please describe the limitation or issue here, and how our leaders can best help {{answer_49757534}}. *

 
Do you have another student in your household who will be attending the retreat? *

     
 
What is your next student's first name? *

 
What is {{answer_49758027}}'s last name? *

 
What grade will {{answer_49758027}} be in for the 2017-2018 school year? *


 
Is {{answer_49758027}} a boy or a girl? *


 
What is {{answer_49758027}}'s shirt size? (adult) *


 
What is {{answer_49758027}}'s cell phone number? (if they have one)

 
Does {{answer_49758027}} have any food or medical allergies that we should be aware of? *

     
 
Please list all allergies here: *

 
Does {{answer_49758027}} have any physical or mental limitations or issues that will requires special assistance from leaders during the retreat? *

     
 
Please describe the limitation or issue here, and how our leaders can best help {{answer_49757534}}. *

 
Do you have another student in your household who will be attending the retreat? *

     
 
What is your third student's first name? *

 
What is {{answer_49760779}}'s last name? *

 
What grade will {{answer_49760779}} be in for the 2017-2018 school year? *


 
Is {{answer_49760779}} a boy or a girl? *


 
What is {{answer_49760779}}'s shirt size? (adult) *


 
What is {{answer_49760779}}'s cell phone number? (if they have one)

 
Does {{answer_49760779}} have any food or medical allergies that we should be aware of? *

     
 
Please list all allergies here: *

 
Does {{answer_49760779}} have any physical or mental limitations or issues that will requires special assistance from leaders during the retreat? *

     
 
Please describe the limitation or issue here, and how our leaders can best help {{answer_49757534}}. *

 
Who is your medical insurance provider?

 
What is your medical insurance account number?

 
We're having parents picking up and dropping off directly at the camp (about a two hour trip from Emergence), and it would be helpful to have parents carpooling together. Please indicate how you would like to participate in carpooling for this trip: *


 
Please carefully read the following: *

I am the parent/legal guardian of this minor. I warrant that I possess all of the rights, powers, and privileges of a parent/legal guardian necessary to execute this document with binding legal effect.

I personally assume, on my child’s behalf, all risk in connection with said activities for any harm, injury or damages that may befall my child as a result of my child’s participation in the activities, whether foreseen or unforeseen, and I still wish to allow my child to proceed with the activities.

In consideration of my child being allowed to participate in these activities and to use available equipment and facilities, on behalf of my child, I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Emergence Church and all of its staff and volunteers, from any and all claims, demands, or causes of action, which are in any way connected with my child’s participation in these activities or use of, equipment and facilities. I understand that it is my obligation to inform the church of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities while in the care of Emergence Church. Should the need for medical attention arise the church will attempt to contact me as soon as practicable under the circumstances.

In cases of emergency, I further consent to the examination or treatment of my child by a physician duly licensed to practice medicine in the United States of America or any health care professional duly licensed to provide heath care serviced in the United States of America for medical care and services deemed necessary by the doctor, its agents, servants, and employees. I give permission to the doctor or health care professional to provide any and all medical care they deem, in their professional opinion, to be necessary. I agree to pay for any and all medical expenses incurred as a result of the use of this consent.

I acknowledge by signing this document, that if anyone is hurt or property is damaged during my child’s participation in these activities, I may be found by a court of law to have waived my right to maintain a lawsuit against the church on the basis of any claim form which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions remain in full force and effect. I have fully informed myself to the contents of this PARENTAL AUTHORIZATION, CONSENT AND RELEASE by reading it before I signed it.
I understand that in the event that my child is involved in any activities that Emergence deems inappropriate, I may be contacted and will assume the responsibility of providing immediate transportation home for my child.
     
 
The cost for this trip is {{var_price}}, which includes lodging, meals, and use of the facility at Rock Mountain. 

PLEASE NOTE:
If you would rather pay by another method, please leave all payment fields blank and you will be able to submit the form. You will then be contacted personally about your preferred method of payment.

Since we are not paying for any sort of transportation from Emergence, but rather dropping off and picking up directly at the camp, we were able to significantly reduce the cost for the trip.
 
Please enter your Credit or Debit Card number:

 
The CVC number:

(3 or 4 digit security number on the back of your card)
 
The name on your card:

 
Your card's expiry month:


 
Your card's expiry year:


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