GLR EVENT REGISTRATION FOR ADULTS

Unity Chapter or New Thought Chapter

Name

Nickname for nametag

Participant is an:

Adult YOU Grad

Date of Birth

T-Shirt Size (adult sizing)

XS S M L XL 2XL 3XL

Gender

Cabin Preference

Male Female Gender Neutral

Home Address

Phone Number

Email (Confirmation email sent here)

This address will receive a confirmation email

Emergency Contact Name

Emergency Contact Phone

First Retreat

Yes No

Number of Retreats Attended

DIETARY HISTORY

Meal Preference (Check all that apply)

Vegetarian Vegan Omnivore Gluten free Lactose Intolerant

List Food Allergies

Non Life-threatening food sensitivites

MEDICAL HISTORY

The above-named participant is in good health and is able to participate in all event activities. Please select one option.

Yes No

If no, specify limits of participation.

Allergies to Medicine

Yes No

If yes, please list:

Participant is currently under a Doctor's supervision for: (Please select one option.)

Epilepsy Diabetes Asthma ADD/ADHD Other Not under a Doctor's Care

If other,or special care needs, please list:

Date of Last Tetanus Shot

Family Physician (Optional)

Family Physician Phone (optional)

Medical Insurance Company

Medical Insurance Phone

Policy Holder's Name

Policy Number

Liability Release

TRANSPORTATION:
I understand that I am responsible for the mode of my transportation for this Event. If I need to be sent home for any reason, including breach of the Event Sponsor Heart Agreements or medical reasons, I agree it will be at my expense.

I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to Great Lakes Unity Region (the Region) events and activities and travel, understanding that some activities may pose a risk of injury. I understand that reasonable measures will be taken to safeguard my health and safety. Whenever it may be deemed necessary, I authorize and consent to the calling of a doctor and/or the providing of other medical services and, unless covered by insurance, agree to pay for same. I agree to indemnify and hold harmless from responsibility, the Association of Unity Churches Inc. (d/b/a Unity Worldwide Ministries(UWM)) the Church/Ministry, and the Great Lakes Unity Region (the Region), its volunteers, designees, employees, agents and event/youth group leaders for any injury, illness or property damage no matter how caused.

I have read this complete document and I understand and consent to all terms contained herein.

Signature Required, This is legally binding

PHOTOGRAPHY:

I hereby grant the GLR and it's representatives, permission to use photographs and videotaped images from this event in which I appear. in any manner whatsoever, such as but not limited to publication, display, advertising, sliude shows, etc.

Please select one option.

Yes No

Participant Signature Required:

CONFIDENTIALITY:

I understand that health information on this form will be secured and will only be shared, as needed, with adult leaders, church staff and medical professionals to safeguard and support the participant. This informatiobn will not be publicly disseminated or released to any outside organization.

Please select one option.

Yes No

Participant Signature Required:

HEART AGREEMENTS

Please click on the link to the Heart Agreement that applies to you. Make sure you read the Heart Agreement fully.

Adult Heart Agreement

YOU Grad Heart Agreement

Type Your Signature that You Have Read and will Follow the Heart Agreement

GLR EVENT REGISTRATION FOR ADULTS

Description

Please Fix the Following