Winter Retreat - January 12-14
This form is to be filled out by a parent/guardian.
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What is your first name (the parent/guardian)? *

 
What is your last name? *

 
Parent's cell phone number? *

 
One at a time! What is your student's first name? (if you have more than one student going, start with the oldest) *

 
What is your student's last name? *

 
What grade is {{answer_JrYpDBysckGK}} in? *

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

 
What is {{answer_JrYpDBysckGK}}'s adult shirt size? (S, M, L, XL) *

 
Student's cell phone number? If they don't have a cell phone put "NA"

 
And what is your home address? *

 
Does {{answer_JrYpDBysckGK}} have any allergies or medical issues we need to be aware of? (please explain briefly) *

 
Will {{answer_JrYpDBysckGK}} require special assistance from leaders during the retreat? (please explain briefly) *

 
Will {{answer_JrYpDBysckGK}} be skiing or snowboarding? *


 
Does {{answer_JrYpDBysckGK}} need to rent skiing/snowboarding equipment? *


 
Do you have another student attending the retreat? *

     
 
One at a time! What is your next student's first name (if you have more than one student going, start with the oldest)? *

 
What is your student's last name? *

 
What grade is {{answer_srLgj4RMRJaC}} in? *

 
Is {{answer_srLgj4RMRJaC}} a boy or a girl? *

 
What is {{answer_srLgj4RMRJaC}}'s adult shirt size? (S, M, L, XL) *

 
Student's cell phone number? If they don't have a cell phone put "NA"

 
Does {{answer_srLgj4RMRJaC}} have any allergies or medical issues we need to be aware of? (please explain briefly) *

 
Will {{answer_hKlsehXHyyoM}} require special assistance from leaders during the retreat? (please explain briefly) *

 
Will {{answer_srLgj4RMRJaC}} be skiing or snowboarding? *


 
Does {{answer_srLgj4RMRJaC}} need to rent skiing/snowboarding equipment? *


 
Do you have another student attending the retreat?

     
 
One at a time! What is your next student's first name (if you have more than one student going, start with the oldest)? *

 
What is your student's last name? *

 
What grade is {{answer_zDLPStNngJu9}} in? *

 
Is {{answer_zDLPStNngJu9}} a boy or a girl? *

 
What is {{answer_zDLPStNngJu9}}'s adult shirt size? (S, M, L, XL) *

 
Student's cell phone number? If they don't have a cell phone put "NA"

 
Does {{answer_zDLPStNngJu9}} have any allergies or medical issues we need to be aware of? (please explain briefly) *

 
Will {{answer_zDLPStNngJu9}} require special assistance from leaders during the retreat? (please explain briefly) *

 
Will {{answer_zDLPStNngJu9}} be skiing or snowboarding? *


 
Does {{answer_zDLPStNngJu9}} need to rent skiing/snowboarding equipment? *


 
Do you have another student attending the retreat?

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

 
What is your student's last name? *

 
What grade is {{answer_o3YUcC3cmYUx}} in? *

 
Is {{answer_o3YUcC3cmYUx}} a boy or a girl? *

 
What is {{answer_o3YUcC3cmYUx}}'s shirt size? (S, M, L, XL) *

 
Student's cell phone number? If they don't have a cell phone put "NA"

 
Does {{answer_o3YUcC3cmYUx}} have any allergies or medical issues we need to be aware of? (please explain briefly) *

 
Will {{answer_o3YUcC3cmYUx}} require special assistance from leaders during the retreat? (please explain briefly) *

 
Will {{answer_o3YUcC3cmYUx}} be skiing or snowboarding? *


 
Does {{answer_o3YUcC3cmYUx}} need to rent skiing/snowboarding equipment? *


 
Medical Insurance - Policy Name

 
Medical Insurance - Policy Number

 
Please 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}}. Because we make payments for the retreat well in advance, if there is a change and your student is unable to attend the retreat let us know as soon as possible. A full refund is available until 12/15, 50% until 12/25, and no refunds will be offered as of 12/26.

As with all of our Student Ministries trips, we always do our best to accommodate families in all financial situations. If this amount is prohibitive for your family to give your child(ren) this great opportunity, please don't pay now.

Please contact Nate Dorka (nate.dorka@emergencenj.org) or Ryan Denos (ryan.denos@emergencenj.org) to request financial assistance through the Emergence Benevolence Fund. We love your kids too much to see them turned away from this trip because of financial restrictions. Thanks!
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Thanks for signing up! See you January 12th!
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