Snow Jam 2022 3/28-4/1

Registration information

To Be Completed by Parent/Guardian. Can be completed by student if 18+ years old. .

Student Information

Student Name

Student Cell

Date of Birth

Parent Guardian Information

Name of Parent / Legal Guardian

This address will receive a confirmation email

Parent Phone

Address

Release of liability and medial information

Please read and sign below...

I hereby consent to & authorize my child (above) to participate in “Snow Jam 2022” conducted by Grace Community Church on March 28-April 1, 2022. We further authorize my child (above) to travel with representatives of the Church in private or church vehicles. If a parent, family physician, or dentist cannot be contacted promptly, and a medical or dental emergency has been determined to exist, the undersigned parent or guardian of the child named above hereby authorizes any representatives of the Church for and on behalf of the undersigned, to consent to any x-ray, anesthetic, medical, surgical or dental diagnosis of treatment and any hospital care deemed advisable and rendered by any licensed physician, or surgeon, EMT, nurse, or dentist, whether in his/her office or in any licensed hospital or health care facility. This authorization is given in advance of any such required care for purposes of empowering any such representative or official of the Church to give the above described consent for any such medical, or dental, as he/she may deem advisable. We herby agree to pay any and all reasonable charges incurred as a result of any such medical or dental treatment and to hold the Church and its representatives and officials harmless. The undersigned hereby release the Church and its authorized representatives and officials of and from any and all liability to the undersigned arising out of or in connection with activities related to the Church, or any travel connected therewith, except for such liability as may arise from the gross negligence or willful misconduct on the part of the Church or its representatives or officials. To the extent that any applicable law prevents or prohibits the under signers’ release of the Church from any liability to child(above) as set forth herein, we hereby agree to indemnify and hold harmless the Church and its representatives and officials of and from any such liability as may be imposed upon any of them.

I have read and agree to the terms above

If my students becomes a discipline problem, I understand that I may be required to pick them up or arrange for their immediate transportation home at my expense. This will be determined by the youth leaders, and all monies for the trip are non-refundable.

I have read and agree to the terms above

Electronic Signature

Medical Insurance Company

Medical Insurance Policy/Group Number

Does the student take and medications or have any food allergies. (If so please explain)

My student may be given ibuprofen for headaches/pain at the leaders discretion/discernment

Yes No

Ski/Snowboard Information

Note: You will be responsible to purchase lift tickets and rentals for the days that you would like to go skiing or snowboarding.

For planning purposes what activity will you most likely be doing?

Skiing Snowboarding I will Not be skiing or snowboarding

Form of Payment

Please choose one of the payment options below. If you would like to make multiple payments then please fill out the form again with desired amount or contact Matt @ 858-945-7966

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Snow Jam 2022 3/28-4/1

Description

Please Fix the Following