Life INC Hill City Winter 2024 Registration
Name
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First Name
Last Name
Email
*
example@example.com
Birthday
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Can we text you at this number? (opt in to receiving text messages)
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Yes
No
Emergency Contact Name and Phone Number
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List everyone living in your home, including yourself, along with date of birth, relationship to you, if they are attending Life INC with you, and any allergies or medical issues they may have. Example: John Doe, 4/19/76, myself, attending, no allergies Jane Doe, 7/21/68, wife, not attending, no allergies
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Some classrooms have stairs. Do you need any accommodations?
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Which class would you like to take?
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Grief Share (Tuesday nights Jan. 21 - Apr. 29)
Realign Financial Management (Tuesday nights Jan. 21-Mar. 11)
Child Photography Release Without compensation, I hereby grant permission to Love INC of the Black Hills and other participating organizations to use and re- produce photographs taken of my child. These photographs may be used for news and editorial purposes in publications, electronic reproductions (web sites), and/or brochures. In addition, I grant my permission to alter the same photos without restriction and to copyright the same. I hereby release the photographer, the journalists, and the publications or media outlets they represent, as well as Love INC and other participating organizations, from all claims and liability relating to said photographs.
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I have read and understood the child photography release
Waiver and Release of Liability On behalf of myself, my heirs, successors and assigns, my participating children, and those children of which I have been appointed to act as a legally appointed representative, I waive and release all claims for damages which we may have against Love INC, and churches, religious denominations or organizations participating in a Love INC event, and any agent or employee of any such organizations, arising from our death, injury, or illness arising from our participation. I am aware of the risks associated with volunteering or participating in Love INC of the Black Hills, including but not limited to, death or by accident, disease, weather conditions, inadequate medical services and supplies, criminal activity and random acts of violence. I voluntarily assume all such injury risks. I agree that this assumption of risk is intended to be as broad and inclusive as permitted by law. I authorize the release of information regarding Life INC participants' attendance and graduation records. Love INC may release this information to partner agencies including but not limited to the Department of Social Services and Habitat for Humanity.
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I have read and understood the waiver and release of liability
I have carefully read the foregoing assumption of risk and understand its contents, and I voluntarily sign this release as my own free agent. I also have read and agree to the child photography release
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Signature of other adult attender
Submit
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