My Blackhawk
My User Account
My Purchase History
My Groups
Give Now
My Internship / My Go Team Trip
Back to Home
»
Login
»
anonymous
Event Registration
Back to Event Detail
Madison Missions 2024 Week 2 on Sunday, July 7, 2024 @ 3:30 PM
Login
Price:
245.00
*
Attendee's First Name:
*
Attendee's Last Name:
*
Attendee's Email Address:
*
Attendee's Phone Number:
Country:
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
China, Hong Kong Special Administrative Region
China, Macao Special Administrative Region
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Cote d'Ivoire
Democratic People's Republic of Korea
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of Korea
Republic of Moldova
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French Part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
State of Palestine
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Thailand
The former Yugoslav Republic of Macedonia
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United Republic of Tanzania
United States Minor Outlying Islands
United States Virgin Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Viet Nam
Wallis and Futuna Islands
Western Sahara
Yemen
Zambia
Zimbabwe
Address Line 1:
Address Line 2:
City, State Zip:
AA
AE
AL
AK
AP
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
**IF YOU NEED A SCHOLARSHIP OR PAYMENT PLAN, STOP HERE**
Please first fill out our
SCHOLARSHIP REQUEST FORM.
We will be in contact shortly, and will ask you to register at that time.
Parent/Guardian 2: First & Last Name:
Parent/Guardian 2: Email:
Parent/Guardian 2: Cell Phone:
*
Gender (for sleeping assignments)
-- Select --
Male
Female
Undecided
*
Current grade (23/24):
-- Select --
Sixth
Seventh
Eighth
*
Does this student attend Blackhawk Community Group?:
-- Select --
Yes
No
If so, which Community Group do they attend?:
-- Select --
N/A
Waunakee
Mt. Horeb
Fitchburg
Brader Way
AASM
If known, who is your student's small group leader?:
If they attend another church, where do they attend?:
How did you hear about Madison Missions?:
*
Madison Missions groups are often co-ed. Name three friends whose group your student would like to be in,
in order of preference
(we can't guarantee these requests, but we will do our best). Use N/A if needed.
*
Student T-shirt size:
-- Select --
Adult Small
Adult Medium
Adult Large
Adult XL
Adult XXL
*
By checking this box, I understand and agree that if my child begins to show signs of being ill during camp, at the discretion of staff, I am responsible to pick them up.
HEALTH & MEDICAL INFORMATION
*
Insurance Company:
*
Account & Group #:
*
List any allergies you have (food, drug, or other):
*
Will your student carry an epi-pen?:
Yes
No
If yes, where will the epi-pen be kept?:
*
Prescriptions and Medications: All medication, both over-the-counter and prescribed medication, must be carried by the participant in its original manufacturer's packaging labeled with the participant's name. Prescribed medication must be supplied in a pharmacy-labeled container indicating the patient's name, correct dosage and administration instructions. List ALL prescription and over-the-counter medications you will be taking during the event, including dosages and frequency.
Students will be allowed to self-administer medication, unless you indicate that you prefer Madison Missions staff to track and administer.
*
Do you want Madison Missions Staff to track and adminster the medications listed above?:
Yes
No
*
Parent/Guardian initials:
*
Physical Health:
List current or past physical conditions, recent illnesses, or health concerns that it could be helpful for program staff to be aware of.
*If your child has a specific medical condition or special consideration that will need monitoring during Madison Missions, we ask that you provide a detailed care plan, and email it to madisonmissions@blackhawkchurch.org
*
Mental Health:
List current or past mental health challenges your child has had (i.e. depression, bipolar disorder, generalized anxiety disorder, history of psychiatric treatment or hospitalization, etc.)
EMERGENCY CONTACT (if parents/guardians listed above are unavailable)
*
Full Name:
*
Phone Number:
*
Relationship to student:
APPEARANCE RELEASE
As the legal parent/guardian for the minor child/student attending this event, I understand that photographs and/or videos may be taken of my minor child/student during the course of this event. I authorize and consent to the use of images or videos of my minor child/student by Blackhawk Church for purposes including, but not limited to, promotional materials, internet posts including social media, and other media sources.
*
I agree:
Yes
No
*
Parent/Guardian initials
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 Madison Missions 2024 (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”), all over the Madison and surrounding areas, 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
*
Joint guardian authorization is required to confirm this minor’s registration (e.g., due to custody agreement).
No. (The parent/guardian signing above has sufficient authorization.)
Yes. (An additional parent/guardian needs to confirm this minor's registration.)
This promo code section is used for scholarships:
Promo Code:
Add
Registration Total:
Next