Great Lakes Project Timothy Registration Form

Great Lakes Project Timothy Registration Form

Great Lakes Region: Everything except payment is included in this form! This form includes your (1) application, (2) liability waiver, and (3) a place for you to select someone to do your recommendation. Once you are accepted you will receive an email with instructions on how to pay the $250 fee.
Student Name *

First Name Last Name
Student Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Student Phone Number *
Please enter a valid phone number.
Age
*
Birthdate
Date*
Gender
*
Are you currently a leader in your church? *
To attend Project Timothy, you have to commit to serving in your Youth Ministry for the next year. Do you commit to leading in your Youth Ministry? *
Do you commit to paying the $250 registration fee if you are accepted? *
Are you Vegan or Vegetarian? *
Please list any food allergies you have. *
Have you ever been convicted of a crime? *
Have you ever been convicted or accused of child abuse/sexual abuse or have you been involved in any activities related to abusing/molesting children or a youth? *
Please upload a short essay (no more than 500 words) describing why you would like to attend Project Timothy. *

Cancel of
Parent Information
Parent Name (Please indicate one parent for contact purposes) *

First Name Last Name
Parent Email *
example@example.com
Parent Phone Number *
Please enter a valid phone number.
Church Informaton
Church Name *
Senior Pastor *

First Name Last Name
Youth Pastor *

First Name Last Name
Email for the pastor that will fill out your recommendation form. *
example@example.com
Medical Waiver/ Liability Release

This section must be completed by a parent or guardian for applicants under the age of 18.
Allergies *
Medications *
Doctor's Name *

First Name Last Name
Doctor's Phone Number *
Please enter a valid phone number.
Other Health Information
Insurance Company *
Policy Number *
Subscriber's Name *
Group Name or Number *
I, as a parent/legal guardian of the minor, understand that my child will be attending Project Timothy at Christ The King Vineyard in North Olmsted, OH. I understand that during this time he/she will be accompanied by volunteers from this and other Vineyards in our region under the direction of staff and volunteers from the Great Lakes Region of the Vineyard, Quest Vineyard Church, and Christ The King Vineyard Church.

I hereby release Quest Vineyard Church, Christ The King Vineyard Church, as well as any other Vineyard church that provides volunteers staff, and/or any sponsors of the event, from responsibility and liability for any loss, injury, or illness that my child may sustain during any activity or event while at Project Timothy. In the event of an emergency, I understand that every reasonable effort to contact me will be made. In the event that I am unable to be contacted, I hereby authorize an adult leader, as agent for me, to consent to any medical, dental, or surgical diagnosis; X-ray examination; and/or hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state or province where the services are rendered, either at the doctor's office or in any hospital.

In the event treatment is required from a physician and/or hospital personnel designated by the church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by a health insurance provider. Further, I affirm that the health insurance information provided below is accurate at this date and will, to the best of my knowledge, still be in force for the student named above and it is my responsibility to ensure that the information is up to date. I also agree to provide transportation at my own expense should they become ill or if it is deemed necessary by the student ministry staff member.
By checking "Agree," you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. *

Agree
Signature *

Clear
Date *

Month Day Year
Date
Please verify that you are human *
Should be Empty:

Great Lakes Project Timothy Registration Form

Parent Information

Church Informaton

Medical Waiver/ Liability Release