Registrant

First Name

Last Name

Mobile

Birthday

/ /

Gender

Campus you regularly attend

Please list any dietary restrictions and/or food allergies

Please list any other known allergies

Health Insurance Provider Name

Health Insurance Policy Number

Emergency Contact Name

Emergency Contact Phone Number

Liability Release

I acknowledge that participation in Summer Weekend with Mountain Young Adults involves risk to the participant (and to the participant’s parents, guardians, and family members), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, and personal injury. In consideration for the opportunity to participate in Summer Weekend, the participant acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant accepts personal financial responsibility for any injury or other loss sustained during the Summer Weekend or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the church staff or volunteers. By checking this box, I agree to the above terms and conditions.

Medical Release

Please indicate whether you agree: I give permission for medical attention to be given to my son/daughter in case of injury, including major surgery. I understand that I will be contacted as soon as possible in case of an incident.

Additional Options

If you're able, choose from the following amounts to make a donation.