Event Registration

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HSM Backpacking Trip 2020 - Student Registration on Saturday, June 20, 2020 @ 11:00 AM

675.00
*Gender:
*Grade:
*Group:
*Are you a guest of someone?:
If yes, who?:
Please note that we will do our best to honor your requests, but we cannot guarantee your group requests.:
Student/Leader Requests:
*Health Insurance Company:
*Account & Group Number:
Allergies or Medical/Dietary Needs:
*Emergency Contact Name:
*Emergency Contact Relation:
*Emergency Contact Phone:
*Parent 1: Name:
*Parent 1: Email:
Parent 2: Name:
Parent 2: Email:
Appearance Release: As the legal parent/guardian for the minor/student attending this programming, I understand that photographs and/or videos may be taken for my minor/student during the course of this programming. I authorize and consent to the use of images or videos of any minor child/student by Blackhawk Church for purposes including, but limited to, promotional materials, internet posts including social media, and other media resources. 
*Consent:
RELEASE & WAIVER OF LIABILITY, ASSUMPTION OF RISK & INDEMNITY AGREEMENT
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 the participant might suffer during the EVENT and ACTIVITIES that are a result of an accident, your own intentional acts 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, negligent or reckless acts. Please read the waiver carefully before signing.
IN CONSIDERATION of access to and participation in [HSM Backpacking Trip] (the "EVENT") including but not limited to transportation, physical activity directly or indirectly associated with the EVENT, etc. (the "ACTIVITIES") hosted by Blackhawk Evangelical Free Church (the “host”), at [Noah's Ark], on [June 20-27, 2020], 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 and ACTIVITIES which he or she may participate in involve risks (e.g., transportation, physical activity); (ii) he or she understands that there are significant risks associated with participation in the EVENT and ACTIVITIES, including by way of the possibility of serious injury or death; (iii) he or she understands that the EVENT and 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 if an injury or health situation occurs during the EVENT and ACTIVITIES; and (v) he or she is in sufficient physical condition and is physically able to undertake all acts related to the EVENT and ACTIVITIES; 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.
*1. Parent/Guardian initials
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 THEREFORE ON ACCOUNT OF INJURY TO THE PERSON OR PROPERTY OR RESULTING IN DEATH OF THE UNDERSIGNED ARISING OUT OF OR RELATED TO THE EVENT AND ACTIVITIES, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES).
*2. Parent/Guardian initials
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 AND ACTIVITIES WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE (BUT NOT INCLUDING INTENTIONAL OR RECKLESS ACTS OF THE RELEASEES).
*3. Parent/Guardian initials
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 AND 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.
*4. Parent/Guardian initials
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.
*5. Parent/Guardian initials
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/Guardian signature
typing your name serves as your signature