Living River Summer Camp Registration

Cahaba Lily Adult Retreat Registration

May 19-21, 2023
General Information
Name*

First NameLast Name
Cell Phone*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please select which housing situation/rate you're reserving:*

Bunk-style Cabin/ $150One Person Booking Room w/Shared Bathroom/ $200Two People Booking Room w/Shared Bathroom/ $350One Person Booking Motel-Style Private Room w/Private Bathroom/ $225Two People Booking Motel-Style Private Room w/Private Bathroom/ $400
If registering two people, who is the other participant not listed above?
Participant's First and Last Name
If in a bunk-style cabin or shared bathroom rooming situation, are there other participants you'd like to be with?
For our planning purposes, please select which activities you're interested in participating in:*

Keynote- Beth Stewart, Cahaba River Society Executive Director Fri., 7:00 pmLily Festival Program and Lunch, West Blocton, Sat., 8:30-12:30Beginner Birding Outing with AL Audubon, Sat., 9:30-10:30Cahaba Lily Excursion with Living River, 10:30-11:30Fish Print Making with Friends of Shades Creek, Sat., 2:00Keynote- Scot Duncan, author of Southern Wonder, Sat., 4:30None of the above (totally fine, too!)
If wanting to attend the Cahaba Lily Festival Program, Lunch, and then go on the festival's lily excursion (bus trip to the lilies or to canoe amongst the lilies with Cahaba River Society), will you have your own transportation to and from West Blocton? You could be back to Living River in time for Scot Duncan's keynote if you chose to participate in the whole festival this way.

Yes, I'll have my own vehicle to take me to and from West Blocton.No, I'll need help getting back to Living River after the festival's lily excursion.
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 the leadership team 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
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

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Payment
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Bunk-style Cabin$150.00

One Person Booking Room w/Shared Bathroom$200.00

Two People Booking Room w/Shared Bathroom$350.00

One Person Booking Motel-Style Private Room w/Private Bathroom$225.00

Two People Booking Motel-Style Private Room w/Private Bathroom$400.00

Test $1.00

Quantity

Total $0.00

Payment Methods

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