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Madison Missions 2024 Week 4 on Sunday, July 28, 2024 @ 3:30 PM

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245.00
**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)
*Current grade (23/24):
*Does this student attend Blackhawk Community Group?:
If so, which Community Group do they attend?:
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:

HEALTH & MEDICAL INFORMATION

*Insurance Company:
*Account & Group #:
*List any allergies you have (food, drug, or other):
*Will your student carry an epi-pen?:
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?:
*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:
*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).

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