Movement Youth Retreat 2026 Registration

Student Information

Name

Address

Date of Birth

Grade Next School Year

Shirt Size

Emergency Contact

In case of emergency, contact (Parent/Legal Guardian)

Name

Phone

Relationship

Authorization

I, as the parent/guardian agree to the following:

I (we) are the parent(s) or legal guardian(s) of the student listed above and grant my (our) permission for him/her to participate fully in MovementChurch.online events and activities.

I (we) understand that MovementChurch.online staff and volunteers will make every attempt to contact me as soon as possible in the event an emergency arises. If I cannot be reached, I (we) authorize MovementChurch.online staff and volunteers to take my child to the hospital to receive medical attention.

I (we) understand that our child may be photographed or videotaped during activities and that these photos/videos may be used in promotional materials published by MovementChurch.online.

Authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.

Medical Insurance Company

Policy #/Medical Record #

List any physical disabilities, condition and/or allergies we may need to be aware of:

List any medications, which your child uses:

Liability Waiver

I, as the parent/guardian, agree to the following:

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity describ
ed above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor (Continued next page) for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

Parent/Legal Gardian Signature

This address will receive a confirmation email

Full Name ex: /John Doe/

Today's Date

Payment

Payment 175.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Movement Youth Retreat 2026 Registration

Description

Please Fix the Following