Event Registration

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HSM Snow Camp Student Registration 2022 on Friday, February 11, 2022 @ 4:00 PM

180.00
*Child lives at the above address:
If you are in need of a scholarship or would like to make a payment plan, please email HSM@blackhawkchurch.org BEFORE continuing on this form, and we will be in contact shortly.  
*Gender (for cabin assignments):
*Grade:
*Birthdate:
*Community Group:
*School attending:
*Students may request up to three friends to be with for cabin assignments - please list them in order of preference (we do not guarantee these requests, but we will do our best)
COVID-19 Mitigation policies: In order to attend camp, students and adults must be vaccinated for COVID-19 or have a negative COVID-19 test within 48hrs of the start of camp. Due to the length of time we will be away and distance of travel it is important for contact tracing to know who is vaccinated/unvaccinated. Vaccination status will not be shared outside of our staff team and will only be used as needed for contact tracing and quarantining while at camp if someone begins showing symptoms of COVID-19 and/or tests positive. Read more detail about our camp COVID policies here.
*Student COVID-19 Vaccination Status (at the time of camp):
I understand and agree to the following COVID-19 mitigation efforts:
*::
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*If your child begins to show symptoms of COVID-19, we will contact you for permission to administer a rapid COVID-19 test. In the event that we are unable to reach you, do you consent in advance to your symptomatic child taking a nasal swab test? 
*Have you previously attended Blackhawk Student Ministries Events?:
*Parent/Guardian First Name (1):
*Parent/Guardian Last Name (1):
*Parent/Guardian Phone (1):
*Parent/Guardian Email (1):
Parent/Guardian First Name (2):
Parent/Guardian Last Name (2):
Parent/Guardian Phone (2):
Parent/Guardian Email (2):
Parent/Guardian address (2): If different from above:
If additional home address listed: Does child live at both addresses?:
*Insurance Company:
*Insurance account & group number:
Allergies or special dietary concerns:
Any other special considerations?:
*T-shirt size:
Emergency Contact (If parent/guardians are unavailable)
*Emergency Contact Name:
*Emergency Contact Phone:
*Relation to student:

RELEASE & WAIVER OF LIABILITY, ASSUMPTION OF RISK & INDEMNITY AGREEMENT

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The following is a liability waiver. By signing the waiver, you are waiving your right to sue or otherwise claim that Blackhawk Church is liable for any injuries or other damages you might suffer during this event/activity that are a result of an accident or your own negligence. The waiver does not release Blackhawk Church from potential liability for injuries or other damages resulting from Blackhawk Church's intentional or reckless acts. Please read the waiver carefully before signing:
:
IN CONSIDERATION of access to and participation in Snow Camp hosted by Blackhawk Evangelical Free Church (the “Host”), at Forest Springs, on February 11-13, 2022. EACH OF THE UNDERSIGNED, for himself/herself, his or her personal representatives, heirs, and next of kin::
:
1. HEREBY WARRANTS AND REPRESENTS that: (i) he or she understands that the particular event/activities which he or she may participate in involve transportation, vigorous physical exercise, including by way of example running, sports activities, activities in cold temperatures, skiing, snowboarding, tubing, ice skating, playing broom ball and prolonged or peak physical activity, (the “Event/Activities”); (ii) he or she understands that there are significant risks associated with participation in the Event and the Activities, including by way of example the possibility of serious injury or death caused by [transportation, falling, exertion, or physical activity]; (iii) he or she understands that the Event/Activities may or may not be supervised by the Host’s employees or agents; (iv) he or she understands that emergency care may not be immediately available in the event of an injury or health event during the Event/Activities; and (v) he or she is in sufficient physical condition and is physically able to undertake all Activities related to the Event; has no disability, impairment or ailment preventing him or her from active or passive exercise, or that will be detrimental to his or her health, safety, comfort or condition if he or she does so engage or participate.:
*Parent or Guardian initials, 1:
:
2. HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the Host or its Elders, staff, sponsors, directors, officers, agents and employees, all for the purposes herein referred to as “Releasees,” FROM ALL LIABILITY, TO THE UNDERSIGNED, his or her personal representatives, assigns, heirs, and next of kin FOR ANY AND ALL LOSS OR DAMAGE, AND ANY CLAIM OR DEMANDS THEREFOR ON ACCOUNT OF INJURY TO THE PERSON OR PROPERTY OR RESULTING IN DEATH OF THE UNDERSIGNED ARISING OUT OF OR RELATED TO THE EVENT/ACTIVITIES, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES).:
*Parent or Guardian initials, 2:
:
3. HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Releasees and each of them FROM ANY LOSS, LIABILITY, DAMAGE, OR COST he or she may incur arising out of or related to THE EVENT/ACTIVITIES WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES).:
*Parent or Guardian initials, 3:
:
4. HEREBY ACCEPTS THE RISK AND ASSUMES FULL RESPONSIBILITY FOR ANY RISK OF BODILY INJURY, DEATH OR PROPERTY DAMAGE arising out of or related to THE EVENT/ACTIVITIES whether caused by the NEGLIGENCE OF RELEASEES or otherwise (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES), and furthermore acknowledges, pursuant to the recreational activities statute, Wis. Stat. § 895.525, that he or she has a responsibility to act within the limits of his or her ability, to heed all warnings regarding participation in the recreational activity, to maintain control of his or her person and any applicable equipment or devices, and to refrain from acting in any manner that may cause or contribute to death or injury for himself or herself or to other persons.:
*Parent or Guardian initials, 4:
:
5. HEREBY acknowledges that prior to signing this Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement, he or she had the opportunity to contact a representative of the Host to discuss and/or bargain regarding any of the terms set forth herein.:
*Parent or Guardian initials, 5:
:
I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE (COVERING THE PARTICIPANT AND ANY OTHER LEGAL PARENT/GUARDIAN) TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.:
:
*Parent or Guardian signature:
typing your name serves as your signature:


APPEARANCE RELEASE
I authorize Blackhawk Church (“Producer”) to make use of my appearance, silhouette and other reproductions of my physical likeness (as the same may appear in any still camera photograph and/or motion picture film), in and in connection with the exhibition, theatrically or otherwise, on the Internet, of any motion pictures in which the same may be used or incorporated, but not limited to this production.I agree that you may tape and photograph me, and record my voice, conversation and sounds, including any performance of any musical composition(s), or other sound effects produced by me during and in connection with my appearance and that you shall be the exclusive owner of the results and proceeds of such taping, photography and recording with the right, throughout the world, an unlimited number of times in perpetuity, to copyright, to use and to license others to use, in any manner, all or any portion thereof or of a reproduction thereof in connection with the Producer or otherwise.I further agree that you may use and license others to use my name, voice, likeness and any biographical material concerning me which I may provide, in any and all media and in the promotion, advertising, and publicizing of Blackhawk Church, and affiliated services, throughout the world in all media, an unlimited number of times in perpetuity. I further represent that any statements made by me during my appearance are true, to the best of my knowledge, and that neither they nor my appearance will violate or infringe upon the rights of any third party.I hereby waive any right of inspection or approval of my appearance or the uses to which such appearance may be put. I acknowledge that you will rely on this permission potentially, at substantial cost to you and hereby agree not to assert any claim of any nature whatsoever against anyone relating to the exercise of the permissions granted here under.
*I agree:
*If you do not agree to the above, please email HSM@blackhawkchurch.org to let us know.

Promo code section is to be used for scholarships. If you are in need of a scholarship or would like to make a payment plan, please email HSM@blackhawkchurch.org BEFORE submitting this form and we will be in contact shortly.