Middle School Retreat Type of Participant(Required) Youth Adult Youth Council Group Leader Name(Required) First Last Preferred NameGrade of Participant(Required) 6th-8th Adult Name of Church You Attend(Required)City of Church You Attend City Group Leader’s Name First Last Group Leader’s Email Group Leader’s Best Contact NumberT-shirt size(Required) Adult Small Adult Medium Adult Large Adult XL Adult XXL Adult XXXL Dietary ConcernsOther Needs for Consideration About Physical or Mental HealthBest Contact Number When On Site For Event(Required)Youth Participation RegistrationParent/Guardian Name(Required) First Last Parent/Guardian Best Contact Email(Required) Grade of Participant(Required)Adult Leader RegistrationYour Email(Required) Please read the guidelines below for adult leadership: Leaders, such as yourself, we be responsible for the wellbeing of youth participants from your church. This includes decisions about contacting the adults responsible for the child if medical or behavioral issues arise. It is the responsibility of leaders to have all medical information for their youth participants. The main group leader for the church should collect this information and make sure that it is available if needed throughout the event. Adult Leaders and chaperones should be above the age of 21 Adult leaders should never be alone with youth, rule of three at all times. Leaders agree to model the respect and compassion of all participants, and will not make fun of parts of the retreat or student participants. Everyone in Tennessee is a mandated reporter under state law. Any person with reasonable cause to believe a child is being abused or neglected must, under the law, immediately report to the Tennessee Department of Children’s Services or to local law enforcement. The reporter can remain anonymous. In addition to reporting to the state, if a leader is to suspect neglect or abuse of a minor by a leader on the retreat, they should also report immediately to a presbytery representative. I have read the guidelines above and agree to follow them(Required) I agree Youth Council RegistrationParent/Guardian Name(Required) First Last Parent/Guardian/Best Contact Email(Required) Parent/Guardian Best Contact Email(Required) Participant Insurance Company(Required)Insurance Policy Holder Name(Required)Participant's Relationship to Policy Holder(Required)Insurance Policy No(Required)Participants Date of Birth(Required) MM slash DD slash YYYY Current Grade(Required)Group Leader/OrganizerAre you attending the retreat(Required) Yes No, But I will be sending chaperones from our church No, I am unable to attend but we are struggling to find chaperones I would like to be contacted about the possibility of merging with another church group. I understand that all chaperones for our church will be over the age of 18, and that I should have one adult for every seven youth.(Required) Yes Please read the guidlines below for adult leadership: Leaders, such as yourself, we be responsible for the wellbeing of youth participants from your church. This includes decisions about contacting the adults responsible for the child if medical or behavioral issues arise. - It is the responsibility of leaders to have all medical information for their youth participants. The main group leader for the church should collect this information and make sure that it is available if needed throughout the event. - Adult Leaders and chaperones should be above the age of 21 - Adult leaders should never be alone with youth, rule of three at all times. - Leaders agree to model the respect and compassion of all participants, and will not make fun of parts of the retreat or student participants. - Everyone in Tennessee is a mandated reporter under state law. Any person with reasonable cause to believe a child is being abused or neglected must, under the law, immediately report to the Tennessee Department of Children’s Services or to local law enforcement. The reporter can remain anonymous. - In addition to reporting to the state, if a leader is to suspect neglect or abuse of a minor by a leader on the retreat, they should also report immediately to a presbytery representativeI have read the guidelines above and agree to follow them(Required) I agree I understand that I will be responsible for collecting medical information and giving to the appropriate chaperones from our church and that the PET and/or JKC are not responsible for the medical treatment of any youth participants from our church.(Required) I agree What is the estimated total number you expect to attend from your group, including adult leaders?(Required)Please enter a number from 1 to 99999.Phone number you can be reached at during the retreat(Required)John Knox Liability ReleaseParticipant Name(Required) First Last Home Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Church Group Name(Required)Church Group Leader(Required) First Last Group Leader Number(Required)Parent/Guardian/Emergency Contact Name(Required) First Last Relationship to Participant(Required)Emergency Contact Phone(Required)Your Email/Email of Parent/Guardian(Required) Grade of Participant(Required)Birthdate of participant(Required) MM slash DD slash YYYY I 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 liability, 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 of 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 with 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 guardian’s expense, with no refund given for the paid cost of the event. I hereby represent that myself and/or my minor is in good health, that I have identified all medical conditions applicable to 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 minor’s 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 understand that the Presbytery of East TN will do all in their power to mitigate the spread of COVID-19 and will ensure proper handwashing stations are available, however, by attending this retreat myself/ my minor is aware that exposure to COVID-19 is an inherent risk in any event where people are present; we cannot guarantee you will not be exposed during this event. 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.Date(Required) MM slash DD slash YYYY PaymentPayment Options(Required) I will be paying for myself/an individual Our church will be mailing a check Individual Payment Quantity(Required)Please enter quantity for the number of individuals you will be paying for. Price: $135.00 Quantity Please list participants names if you are paying for multiple youth.Total Credit Card(Required) PhoneThis field is for validation purposes and should be left unchanged.
