Full Weekend Registration Options

Teen Attendee
Includes housing, 4 meals, metro card and DC United Ticket

Participant Name

Participant Email

Confirm Participant Email

Participant Cell

Gender

Male
Female

Class

Baptism Date (if applicable)

Home Church

Parent/Guardian Name

Parent/Guardian Email

Confirm Parent/Guardian Email

Parent/Guardian Cell

Participant Medical Information

Must be completed by parent or legal guardian of teen participants.

Emergency Contact Name

Relationship to Participant

Emergency Contact Cell

Physician Name

Physician Phone

Medical Insurance Company

Policy Number

Group Number

Medical Insurance Phone

HEALTH HISTORY

ALLERGIES

List all known allergies and how each reaction is managed.

If no known allergies, please list N/A.

Medication Allergies

Food Allergies/Dietary Restrictions

Any Other Allergies

MEDICAL HISTORY

Please list anything from the participant's medical history that might be relevant in the event of a medical emergency. (recent illnesses, chronic conditions, prior surgeries, etc.)

Is there anything else that you'd like chaperones to know to make the participant's trip as successful as possible?

Any activity restrictions? If so, please elaborate.

Date of Last Tetanus Immunization

MEDICATIONS

Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Be sure that the attendee brings enough medication to last the entire weekend in the original package/bottle that identifies the prescribing physician, name of drug, dosage, and frequency.

I understand that there will be no dedicated medical personnel supervising this event and that the participant has my permission to self-administer their own medication.*

WAIVER AND RELEASE OF LIABILITY

This Release and Waiver of Liability (the "Release") is in favor of Capital Rivers Church and all other sponsoring churches, and each of their directors, officers, employees, and agents. I, hereby freely and voluntarily, without duress, execute this Release under the following terms:

In consideration of the risk of injury while participating as a teen participant or adult chaperone at the ACR Upperclassmen Trip, and as consideration for the right to participate in these Activities, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation as a as a teen participant or adult chaperone at the ACR Upperclassmen Trip, and do hereby release and forever discharge Capital Rivers Church and other sponsoring churches, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any physical or psychological injury, including but not limited to illness, exposure to infectious/communicable disease, paralysis, death, damages, economical or emotional loss, that I may suffer as a direct result of my participation in the aforementioned Activities, including traveling to and from an event related to these Activities.

I acknowledge that participation in the activities described above involve risk to the teen participant (and to the participant's parents or guardians, if the participant is a minor) and adult chaperones , and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above (the “activity”), the teen participant (or parent/guardian if the participant is a minor) and/or adult chaperone acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The teen participant (or parent/guardian) and/or adult chaperone accepts personal financial responsibility for any injury or loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the teen participant and/or adult chaperone that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the teen participant (or parent/guardian) and/or adult chaperone releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the volunteer or otherwise.

If a dispute over this agreement or any claim for damages arises, the teen participant and/or adult chaperone (or parent or guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the teen participant (or parent or guardian) and/or adult chaperone and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.

By checking the boxes below, I am indicating my agreement to the following statements:

I understand the Activity Leaders reserve the right to dismiss any participant or volunteer whose behavior/attitude is detrimental to the welfare of the other participants or whose conduct is not in accord with the standards.*

I understand that participants are expected to participate and attend all scheduled activities of the weekend once they have arrived.*

I understand that teenager drivers may ONLY drive themselves and any other participants who rode together to the activity. There will be NO exceptions to this policy.*

I understand that in the event of dismissal or withdrawal on account of homesickness, misconduct or any other cause except for medical emergencies, that no refund will be given. I understand that I will be responsible for picking up my child in the event of dismissal or withdrawal. No special bus transportation or other transportation will be arranged on behalf of my child in this event.*

I authorize the use of the participant's photo in any promotions (website, brochure, etc.).*

Should it be necessary for the above-named participant to receive emergency medical attention or treatment while participating in the trip, I hereby give permission for the person(s) leading or directing the activities, to administer emergency medical treatment (i.e., first aid, CPR, etc.) to the participant or secure the services of an ambulance, hospital, physician or other medical professional to treat the participant as they deem appropriate and necessary. I understand that Capital Rivers Church has no health insurance to cover medical or hospital costs incurred by the participant; therefore, financial responsibility for any medical or hospital costs shall be the sole responsibility of the Parent/ Legal Guardian.*

I understand that none of the volunteers leading or directing these activities may accept responsibility for alerting a participant about required medication or administering such medication.*

I understand that if I register on or before March 24th, 2024 that I will be eligible for a refund minus processing fees. The last day to cancel registration is March 24th. After March 24th no refunds will be given.*

As evidenced by my typed name below, I expressly agree that this Release is intended to be as broad and inclusive as permitted by laws of the State of Maryland in the United States of America, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Maryland. I agree that if in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable.

I affirm that I am of the age of 18 years or older, and that I am freely signing this agreement for myself and/or my family members. I certify that I have read this agreement, that I fully understand its content and that this release cannot be modified orally. I am aware that this is a release of liability and a contract and that I am agreeing to it of my own free will.

Electronic Signature

Running Total

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Coupon Code

Total

$0.00