MANA Registration

MANA Registration
Personal Information
Name*

First NameMiddle NameLast Name
Gender*

MaleFemale
Date of Birth*
Grade Level*

Jr. HighHigh SchoolCollegiateOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email
example@example.com
T-Shirt Size*

SmallMediumLargeXLXXL
Roommate Request
Vegetarian Meals*

YesNo
Guardian's Name #1*

First NameLast Name
Phone Number*

Area CodePhone Number
Guardian's Name #2

First NameLast Name
Phone Number

Area CodePhone Number
Church You Attend
Years Attended
Insurance Information
Do You Have Health Insurance?*

YesNo
If Yes, List Insurance Provider
Do You Have Allergies?*

YesNo
If Yes, List Allergies
Taking Medication(s)?*

YesNo
If Yes, Please List
Emergency Contact
Name*

First NameLast Name
What's Your Relation?
Phone Number*

Area CodePhone Number
In the event of any emergency, I give authority to the accompanying adults to authorize treatment. I understand thatan attempt to notify me will be made before any treatment is authorized. Sign Below.
Parent/Guardian Signature (required if under 18 yrs old)*

Clear
Date*
I understand that I will be attending a Christian function, and must act accordingly. I promise to treat my fellow students and supervising staff with respect and dignity. I will embrace any obstacles with a prayerful heart while accepting my duties with good spirits and enthusiasm.
Parent/Guardian Signature (required if under 18 yrs old)*

Clear
Date*
Agreement for Waiver and Release, Assumption of Risks & Indemnification

rev 1/10
NOTICE: This document affects your legal rights, please read carefully. Handwritten changes to this document are not permitted and will not be honored. This Agreement constitutes the entire Agreement and shall not be modified except via written document, executed by both parties. If any portion of this Agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
MANA

Summer Retreat 2018
Participant Name*

First NameLast Name
Parent / Legal Guardian Name*

First NameLast Name
I acknowledge and understand that certain camping activities, including but not limited to: skating, skateboarding, paintball, ropes courses, archery, marksmanship, water sports, horses and dirt bikes are hazardous and dangerous activities that require strenuous exercise and varying degrees of skill and experience. I understand that these activities can result in serious injury to the person and damage to property and I voluntarily assume any and all risks of loss, damage or injury while on the premises.

I acknowledge that there are risks, hazards and dangers of personal injury, death and disability inherent in entering camp grounds and participating in, or viewing camp activities. I am aware that the usual risks, hazards and dangers of personal injury, death and disability increase when using certain camping equipment and when other persons, whether of the same or different level or experience or skill, are using the same facilities and equipment.

In consideration for my participation, or for the participation of my child or the minor for whom I represent that I am legal guardian, I hereby release and forever discharge Island Lake Camp, Miracle Ranch Camp, and CRISTA Ministries, and their servants, employees, officers, directors, trustees and all other persons or entities acting on their behalf (collectively referred to as “CRISTA”), from any and all claims, actions, damages, liabilities, costs or expenses and attorney fees which are related to, arise out of, or are in any way connected to my, my child’s, or the minor for whom I represent that I am legal guardian’s viewing or participation in any camping activities. By signing this Agreement, it is my intention to waive any rights to sue or seek damages from CRISTA; except where injury, death or disability results from CRISTA’s gross negligence.

I further agree to indemnify, hold harmless and defend CRISTA against any and all claims for damages, costs, expenses or attorneys fees brought by any third party in connection with or arising out of my, or the above-listed participant’s involvement or participation. This Agreement shall be effective and binding upon my marital community, estate, heirs, agents, personal representatives and assigns.
Emergency Consent:
Participant's Name*

First NameLast Name
... may receive emergency and/or routine medical care from a physician or emergency facility if I am incapacitated (if participant), or cannot be reached in an emergency (if parent/guardian).
Photo Release:

CRISTA may publish photos taken of participant and I release all rights to remuneration for such photos.
I hereby certify that I am over 18 years of age; I have carefully read the foregoing and acknowledge that I understand and agree to all the terms and conditions. I have had the opportunity to ask any and all questions regarding this Agreement and the effect of the same. I am aware that by signing this Agreement, I assume all risks and waive and release certain substantial rights that I have or possess.
Participant Signature (on behalf of marital community)*

Clear
Parent/Legal Guardian Signature (on behalf of marital community)*

Clear
Additional Indemnification for Parents/Guardians – Must be completed for participants under the age of 18.

In consideration of
... Minor's Name

First NameLast Name
(“Minor”) participation in Camps activities including the use of Camps equipment and facilities, I further agree to indemnify and hold CRISTA harmless from any and all claims which are brought by, or on behalf of Minor and which are in any way connected with such use or participation by Minor.
Parent/Legal Guardian Signature (on behalf of marital community)*

Clear
Should be Empty:

MANA Registration

Personal Information

Insurance Information

Emergency Contact

Agreement for Waiver and Release, Assumption of Risks & Indemnification

MANA

Emergency Consent:

Photo Release:

Additional Indemnification for Parents/Guardians – Must be completed for participants under the age of 18.