Go M.A.D. Young Adult Retreat

1
Young Adult Participant's Information
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Participant's Name* This field is required.
First Name
Last Name
3
Nickname
4
Participant's Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Participant's Phone Number* This field is required.
Area Code
Phone Number
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Participant's E-mail* This field is required.
example@example.com
7
I am between the ages of 18 - 25* This field is required.
YESNO
8
Please list your roommate requests (most rooms have a maximum of 4 people):
Huge
Large
Normal
Small
Ok
Ok
9
T-Shirt Size* This field is required.Scroll down for all options
Please Select
Please Select
Small
Medium
Large
XLarge
XXLarge
10
Emergency Information
11
Emergency Contact's Name* This field is required.Emergency Contact must be available by phone from Jan. 6 to Jan. 8. Emergency contact must also be available to pick up youth in Ocean City in the event of an emergency.
First Name
Last Name
12
Relationship* This field is required.
Please Select
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Other
13
Emergency Contact Primary Phone Number* This field is required.
Area Code
Phone Number
14
Emergency Contact Alt. Phone Number
Area Code
Phone Number
15
Do you have any allergies, chronic illness, or medical conditions? If yes, please describe. If no, list N/A* This field is required.
16
Are you prescribed any medication? If yes, please explain any instructions. If no, list N/A* This field is required.
17
Informed Consent and Acknowledgement I hereby consent to my participation in any and all activities prepared by Fallston United Methodist Church (FUMC) during the retreat. In exchange for the acceptance of my candidacy by FUMC, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless FUMC and all its respective officers, agents, and representatives from any and all liability for injuries arising out of traveling to, participating in, or returning from selected retreat/camp sessions. In case of injury, I hereby waive all claims against FUMC.
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I give Fallston United Methodist Church (FUMC) representatives the right to take photographs me in connection with all Sunday School, Children’s Ministry, Youth, Young Adult and church events. I understand that FUMC may use such photographs for any lawful purpose, including purposes such as publicity, illustration, advertising, and Web content. I understand that pictures may be used for FUMC's website and/or Facebook page and for in-house video or slideshows. I understand I will not be identified by full name and FUMC will not list or advertise my first and last name with the picture.
YESNO
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Confirmation BY SELECTING SUBMIT, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SUBMIT WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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