Living River Summer Camp Registration

You and Me Retreat- Adult Registration

April 28 - 30, 2023
General Information
Name*

First NameLast Name
Child(ren) I am attending with
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Church
Cell Phone Number*

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact phone number *

Area CodePhone Number
E-mail*
Dietary Allergies/ Restrictions
Do You Require an Epi Pen*

YesNo
Other allergies (bee stings etc)/restrictions
Do you require the use of an inhaler?*

YesNo
List any medical conditions of which leadership teams should be aware
Optional question about vaccination status

i have been fully vaccinated.I have received one dose, but not yet fully vaccinated.I have not been vaccinated.I prefer not to answer.
Acknowledgements and Releases
Photo release and permission to contact*

I give permission for any photos or videos taken of me during the event by the Presbytery of Sheppards and Lapsley and/or Living River to be used for the public relations of the program.I do not give permission
Medical authorization and release*

Should I sustain or incur any accident or illness while at the event, I hereby authorize the Director and/or the Health Care provider to execute any and all documents in my behalf, including necessary releases, which might be required by a medical facility to perform emergency careI do not give permission
Accident Insurance Disclaimer*

I understand I am responsible for all incurred medical expenses while at Living River
Presbytery Youth Protection Policy Compliance*

I understand I am bound by the Presbytery's Youth Protection policy (link on Presbytery's web site and in the confirmation email) and agree to abide by the provisions in it).
Background Check*

I have had a background check with my church within the past 3 years and am on the Stated Clerk's list of approved adult leadersI need the stated clerk to run a background check before I can participate in this event. By clicking this option, I give permission for the Stated Clerk to initiate the background check with Praesidium, our provider. You will receive an email from Praesidium which you can complete online. The results will be sent to the Stated Clerk. If there is a problem, the stated Clerk will be in contact with you.
Covid Waiver

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing. I further acknowledge that the Presbytery of Sheppards & Lapsley and Living River has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19. I further acknowledge that Presbytery of Sheppards & Lapsley and Living River can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to staff and other participants and their families. I acknowledge that I must comply with all set procedures to reduce the spread while attending. I attest that: * I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. * I have not traveled internationally within the last 14 days. * I have not traveled to a highly impacted area within the United States of America in the last 14 days. * I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. * I have not been diagnosed with Coronavirus/Covid-19 . * I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. I hereby release and agree to hold Presbytery of Sheppards & Lapsley and Living River harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property..
I have read and understand the above waiver regarding COVID*

I accept this waiverI do not accept this waiver
Signature

Clear
Payment
Pay Later

Pay by check - made payable to Living RiverPay by PayPal - PayPal invoice sent to me from Living River
Pay Now
prevnext( X )
You and Me Adult Cost$150.00

Total $0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty: