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Participation!Agreement!" In"consideration"for"the"opportunity"to"participate"in"the"Jr.$High$Camp,!the"participate"(or"parent/guardian"if"participant"is"a"minor)"acknowledges"and"accepts"the"risks"of"injury"associated"with"participation"in"and"transportation"to"all"locations"during!our!Jr.$High$Camp.""The"participant"(or"parent/guardian)"accepts"personal"financial"responsibility"for"any"injury"sustained"during"the"Jr.$High$Camp.!!Further,"the"participant"(or"parent/guardian)"promises"not"to"indemnify,"defend,"and"hold"harmless"the"activities"Sponsor"(Real"Life"Community"Church)"or"its"agents,"employees,"volunteers,"or"any"other"representatives"(collectively"referred"to"hereinafter"as"“Sponsor”)"for"any"injury"related"directly"or"indirectly"out"of"participation"in"the"Jr.$High$Camp"or"transportation"to"and"from"the"Jr.$High$Camp,"whether"such"injury"arises"out"of"the"negligence"of"the"Sponsor"or"otherwise.""I"agree"to"release"and"hold"harmless"any"and"all"staff"and"lay"assistants"of"the"Northwest/east"Indiana"District"(NWIN/NEI/NYI)and"or"its"representatives"(Real"Life"Community"Church)"from"any"and"all"claims,"suits,"costs,"and"actions"of"any"kind"whatsoever"arising"from"their"exercise"of"the"power"granted"by"this"authorization,"unless"due"to"verifiable"negligence."""" If"a"dispute"over"this"agreement"or"any"claim"for"damages"arises"the"participant"(or"parent/guardian)"agrees"to"resolve"the"matter"through"a"mutually"acceptable"alternative"dispute"resolution"process.""If"the"participant"(or"parent/guardian)"and"the"Sponsor"(Real"Life"Community"Church)"cannot"agree"upon"such"a"process,"the"dispute"will"be"submitted"to"a"threeNmember"arbitration"panel"of"the"American"Arbitration"Association"for"final"resolution.""

Student/Parent!Statement!of!Understanding!" I"understand"that"the"following"items/activities"are"prohibited"and"will"result"in"the"immediate"dismissal"from"Serve$The$World$Day"without"refund"and"at"the"cost"of"my"parent/guardian.""""

*alcohol"" *tobacco/drugs" " *pornography" " *profanity" *weapons" *fireworks"*fighting"*going"into"the"opposite"sex’s"facilities" "*theft" *inappropriate"attire/displays"of"affection""

Cost"of"transportation"home"will"be"paid"by"the"parent/guardian"signing"below.""

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This!release!is!in!effect!on!date!of!event:!_________________________!!

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X"Parent/Guardian"Signature_______________________________________________" Date:_________________""X"Student"Signature__________________________________________________________""

Parent/guardian!signatures!are!required!regardless!of!the!Student’s!age.!

NEI/NYI!Jr.!High!Summer!Camp!2015!July!17M21,!2015!!|!Shiloh!Park!Retreat!Center!

$160!nonMrefundable!deposit/payment!due!on!or!before!June!8,!2015!!$175!nonMrefundable!payment!after!July!6,!2015!!!!!

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Name"of"Participant:""______________________________________"" Phone:"______________________"""TNShirt"Size:"" S"""""M""""L"""""XL"""""XXL"""""3X""(if"applicable)" Gender:""""""Male"""""""Female" """"""""Grade:"______""PAYMENT"TYPE:"""Cash"_________" Check"______"(#___________)" Date"of"Payment:"_____________" "

Is"your"student"covered"under"a"health"insurance"policy?" " " " " Yes" " No"" (If"you"answered"“No”,"please"fill"out"the"attached"“No"Insurance"Policy"form”"(attached)""

Have"you"previously"completed"the"2014M2015"Student"Information"Form"(attached)?"" Yes" " No"" (If"you"answered"“Yes”,"you"do"not"have"to"reNfill"out"the"form"unless"any"information"has"changed)""

Is"Real"Life"Community"Church"approved"to"authorize"emergency"medial"treatment?"" Yes" " No"

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!Real!Life!Student!Ministries!Electronics!Policy!

!Real"Life"Community"Church"conducts"a"number"of"different"events"for"students."Each"event"is"designed"in"its"own"way"to"promote"a"relationship"with"God"and"fellowship"with"peers."Therefore,"these"events"are"intended"to"provide"a"break"in"the"routine"and"reliance"e"of"one’s"normal"everyday"activities."As"a"result,"Real$Life$is$regulating$the$use$of$electronic$devices$to$enhance$safety,$limit$distraction,$and$promote$spiritual$development."Electronics"such"as"cell"phones,"cameras,"music"players,"and"gaming"devices"are"only"permitted"for"us"during"allotted"times"which"are"to"be"set"my"the"director/coordinator"of"each"event."Real"Life"Community"Church"will"not"be"responsible"for"any"lost,"stolen,"or"damaged"devices."At"any"point,"we"(event"director/coordinators/youth"leader)"reserve"the"right"to"confiscate"any"electronic"device"if"leadership"determines"the"device"is"being"misused,"causing"distraction,"or"used"excessively."Item(s)"will"be"stored"in"a"safe"location"and"returned"at"the"conclusion"of"the"event."""On!occasion!that!any!electronic!device!is!used,!resulting!in!the!violation!of!a!person’s!privacy!or!the!capturing!of!pornographic!images!(with!or!without!intent),!parents!will!be!notified!and!authorities!will!be!contacted!to!handle!investigation."This"policy"is"to"ensure"the"safety"and"protection"of"our"students,"leaders,"and"organization"to"the"best"of"our"abilities."""I"have"read"and"understand"the"Real"Life"Community"Church"Electronics"Policy."I"agree"to"abide"by"these"guidelines"and"I"realize"that"any"misuse"or"abuse"of"electronic"devices"at"any"Real"Life"Community"Church"student"ministries"event"will"have"consequences"as"outlined"above."(Please"note,"this"form"must"be"completely"filled"out"by"all"participants)"""______________________________________________________" " ______________________"Student’s"Name"Printed"" " " " " " " Date"""______________________________________________________" " "Student’s"Signature"""______________________________________________________" " ______________________"Parent/Guardian"Printed"Name" " " " " " " Date"""______________________________________________________" " "Parent/Guardian"Signature"""All"students/adults"attending"a"Real"Life"Community"Church"event"MUST"fill"out"this"from"in"order"to"attend.""" " " "!Contact!Person:!Rich"Evans" "Student"Ministries"Pastor"3134"Swanson"Rd."Portage,"IN"46368""

!Contact!Info:!Web:"revans@reallifecc.org"Phone:"219.762.6544"(office)""Mobile:"219.309.6739"(cell)"Emails:"revans@reallifecc.org

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NWIN!NYI/REALLIFE!CHURCH!STUDENT!INFORMATION!Please"staple"a"copy"(front"and"back)"of"your"student’s"insurance"card/s"to"this"form."If"you"do"not"have"insurance,"please"fill"out"the"“no"insurance"form”"on"the"back"of"this"form."Please!print!!In"case"of"emergency,"we"need"to"be"able"to"read"the"information"you"

Student"Information"

Name" First:" Middle:" Last:"

Address" Street:" City:" Zip:"

Phone" Home:" Parent"Cell:" Student"Cell:"

Email" Parent/Guardian:" Student:"

Student"Birthday:" Grade:" Shirt"Size:" Gender:""""Male_____"Female_____"

Health"Concerns"Are"there"any"health"concerns"of"which"we"should"be"aware?"

Physical"Disabilities" Yes__"No"__" Allergies"to"Medication/Food" Yes___"No___" Serious"Illness" Yes__"No__"

If"you"answered"“Yes”"to"any"of"the"above"questions,"please"explain."You"may"write"on"the"back"of"this"page"if"you"need"more"space."

Doctor’s"Name:" Doctor’s"Phone:" Doctor’s"Address:"

Immunizations"up"to"date:"Yes____"No____"

Tetanus"up"to"date:"Yes____"No____"

Please"list"any"medications"your"student"is"currently"taking:"

Insurance"Information"

Name"of"Health"Insurance"Company:"

Policy"Number:"

Name"of"Responsible"Party:""

Emergency"Contact"

Name:" Relationship"to"Student:"

Student"lives"with"(check"all"that"apply):"Father____"Mother____"Guardian____"(Relationship"to"student______________)"

Photographs"&"Name:"May"we"use"your"student’s"photograph"and/or"name"in"the"areas"listed"below?"Please"circle"answer"

Slide"Shows:"""""Yes"""""No" Social"Media/Websites:"""""Yes"""""No" Brochures:"""""Yes"""""No" News"Articles:"""""Yes"""""No"

By"signing"below,"I"agree"that"this"information"is"correct"and"that"if"any"information"on"this"form"changes,"I"will"inform"the"NWIN/NEI/NYI"&"REAL"LIFE"COMMUNITY"CHURCH"of"said"changes."I,"also,"agree,"by"signing"this"NWIN/NEI/NYI"&"REAL"LIFE"COMMUNITY"CHURCH"Student"Insurance"Information"form,"to"give"my"permission"to"NWIN/NEI/NYI"&"REAL"LIFE"COMMUNITY"CHURCH"to"us"my"student’s"name"and/or"likeness"in"the"areas"of"which"I"indicated"above"by"circling"“Yes”."

Parent/Guardian"Signature__________________________________________" Date____________________""

Printed"Name______________________________________"Parent/Guardian"signature(s)"is"required"regardless"of"student’s"age."

Phone"Number:"

Phone"Number:" Alternate"Phone:"

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No Insurance Form

If there is no insurance for the participant, this form must be filled out and notarized. Please do not sign until you are in the presence of an authorized Notary Public.

As______________________________(name of minor; from henceforth referred to as “Student” is not covered by any type of health insurance policy or program, I,___________________________(name of parent or guardian), on behalf of Student, hereby guarantee payment for any fee, expenses, or costs related to the medical treatment of Student in connection with Student’s participation in events and trips with the Northwest/Northeast Indiana District Nazarene Youth International (from henceforth referred to as “NWIN/NEI/NYI”), Real Life Community Church (from henceforth referred to as “RLCC”), and their sponsors. I understand and acknowledge that I may be asked to provide further guarantees of payment to the health care professionals and institutions that provide medical treatment to Student. I also acknowledge that neither the General Board of the Church of the Nazarene, nor Nazarene Youth International, nor NWIN/NEI/NYI, nor RLCC is responsible for the cost of Student’s medical treatment. I shall indemnify, defend, and hold harmless the General Board of the Church of the Nazarene, Nazarene Youth International, NWIN/NEI/NYI, RLCC their respective officers, directors, employees, agents, and chaperones from and against any and all claims which may be made as a result of my failure to provide payments for Student’s medical treatment. Signature_________________________________________________ Date____________________ Printed Name______________________________________________ Relationship to Student______________________________________ The following section must be completed (in the presence of) a Notary Republic. Before me, a Notary Republic, in and for said county and state, this____day of______________,20___, Personally appeared before me and acknowledged execution of the forgoing. IN WITNESS WHEREOF, I have hereunto set my hand and Notary Seal. STATE OF______________________________________

COUNTY OF____________________________________

Notary Public Signature____________________________

Commission Expiration Date_________________________

Notary Seal: !!!!

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