Pre-Teen Retreat Name(Required) First Last Church/Group Name(Required)Phone(Required)Sex(Required) Male Femal Child or Adult(Required) Child/Youth Adult Chaperone Overnight or Day Only(Required) Overnight Saturday Only $40 for Students and Adults (all activities, 2 meals, & Friday lodging), OR $20 for Saturday only for Students and Adults (all activities & 2 meals)Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact(Required) First Last Relationship to Child:(Required)Emergency Contact Phone #(Required)Participant's Insurance Company(Required)Insurance Policy #(Required)Allergies:Please list all allergies (to medications, insects, food, etc) and explain.Medical/Behavioral Considerations:(Please include all conditions such as diabetes, heart conditions, asthma, ADHD, etc.)Special Dietary Considerations(Vegetarian, Gluten Free, Food Allergies, etc.)Activity Level(Required) yes no Are you able to participate in strenuous activities?Parent/Guardian Name(Required) First Last Mailing Address (if different from above) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Phone(Required)Parent/Guardian's Email(Required) Child's Date of Birth(Required) MM slash DD slash YYYY Child's Age(Required)Current Grade(Required)4th5thI hereby give my permission to the Presbytery of East Tennessee/John Knox Center for me or my minor, child or ward (collectively "minor") to participate in all activities and further agree to the terms herein contained. On behalf of my minor and/or myself, to participate in John Knox Center (hereinafter collectively referred to as JKC/ PET) activities and to use its equipment and facilities, I agree to release, indemnify, hold harmless, and covenant not to sue JKC/PET, its employees, agents or volunteers for any and all liabilfty, claims, demands, or causes of action which may be brought by myself, my minor, or on behalf of either of us, and which are In any way connected with such use or participation by my minor or myself, whether caused by the negligence ot JKC/PET, its employees, agents, or volunteers, or otherwise. I acknowledge that myself or my minor's participation in individual and group initiatives, problem solving exercises, high ropes elements, and personal growth and development training activities entails known, perceived, and unanticipated risks that could result in serious physical or emotional injury, permanent disability, or death. I understand that such risks simply cannot be eliminated without jeopardizing the essential qualities of the activity and I expressly accept and assume on behalf of myself and/or my minor all the risks existing in these activities. I authorize JKC/PET personnel to call for medical care or to transport myself or my minor to a medical facility or hospital if, in the opinion of such personnel, medical attention is needed. I agree to pay all costs associated with such medical care and transportation. I understand that every guest at the John Knox Center site is covered by secondary insurance, with the participant's Insurance being the primary party in claims situations. I also agree to comply JKC/PET rules and policies and to cooperate with JKC/PET personnel. I understand and agree that if myself or my minor fail to comply with the rules and policies, s/he may be asked to leave the event at the parent or legal guardians expense, with no refund given for the paid cost of the event. I hereby represent that myself and/or my minor is in goo_d health, that I have identified all medical conditions applicable lo participation, and that I have adequately informed JKC/PET personnel of any special instructions. I certify that I have adequate Insurance to cover any injury or damage my minor or I may suffer while participating, or I agree to bear the costs of such injury or damage myself. I give my permission to allow JKC/PET to use my likeness and/or my minors In photos and videos In any form of media for publicity and reporting purposes (print, digital, online, etc.). I agree that this release, waiver, and Indemnity and other terms herein are intended to be as broad and inclusive as permitted by the law of the State of Tennessee and if any portion is invalid, the remainder shall continue in force. I have read the above and acknowledge the information stated on this form is complete and correct. By signing or typing my name below, I agree that this wet inked or electronic signature is valid. I understand that an electronic signature is legally binding in Tennessee.Adult Chaperone or Parent/Guardian Signature(Required)Total Credit Card(Required)
