Kairos Summit Registration

Kairos Summit Registration Form

Thursday, July 3 - Monday, July 7, 2025, Mark Twain State Park, Missouri, $400, Registration will close May 20
Youth and Guardian Information

Youth's Information
Youth Name*

Youth First NameYouth Last Name
Youth Email*
example@example.com
Youth Sex*

FemaleMale
Member of Community:*

Ann Arbor - Word of LifeColumbus - CornerstoneDallas - Families For ChristGrand Rapids - Light of ChristKansas City - Heart of the RedeemerLansing - Work of ChristLivonia - Christ's Ardent Disciples in ActionLos Angeles - City on the HillMaryland - Triumph of the CrossMiami - Comunidad La Nueva JelusalénMinnesota - Community of Christ the RedeemerNew Jersey - Family of FaithNew Jersey - People of HopePhoenix - City of the LordPittsburgh - People of GodSeattle - Beacon of JoyTallahassee - Fountain of LifeToronto - Jesus the Good ShepherdToronto - One With God CommunityVancouver - Families for Christ CommunityOther (not a member of one of these Communities)
City and/or community that you're coming from*
Name of person inviting you (if coming as guest)*
Year in High School*
Youth Birth Date*

MonthDayYear
Date
Tradition or Church Background*

AnglicanBaptistCatholicLutheranNon-DenominationalOrthodoxPresbyterianReformedOther
Sweatshirt size (Sweatshirts are unisex sizes)*

SmallMediumLargeExtra-LargeXXL
Guardian's Information
Registering Parent's Name*

Parent First NameParent Last Name
Registering Parent's Email*

Confirmation EmailConfirm Registering Parent's Email address
Registering Parent's Phone Number*
Please enter a valid phone number.
Other Parent's Name*

Parent #2 First NameParent #2 Last Name
Other Parent's Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState/Prov. Code

Zip Code
Emergency Contact
Emergency Contact's Name*

Emergency First NameEmergency Last Name
Emergency Contact’s Relationship to Participant*
Emergency Contact's Phone*
Please enter a valid phone number.
Part 3 of 4: Medical Information
All trip participants must have medical insurance. If a participant does not have medical insurance, medical insurance must be purchased in advance and specific information pertaining to that policy should be included here or sent to trip staff before the trip. Kairos, their agents, employees, or volunteers will not be responsible for medical expenses incurred during a trip.
Family Health Insurance Provider*
Health Insurance Card Holder's Name*
Health Insurance Policy Number*
Doctor's Name*
Doctor's Phone Number*
Does your child have any dietary allergies or concerns?*

NoYes
Dietary allergies or concerns explanation*
Please explain the dietary allergies or concerns your child has. Kindly also inform us of their severity i.e. type of reaction (rash, hives, difficulty breathing, vomiting). There is a refrigerator available for those needing to bring special foods. We can also make some accommodations within our planned menu if notified in advance. Do let us know if your child plans to bring their own food.
Is your child currently taking any medications?*

NoYes
Current Medications List:*
Please list and explain the medications your child takes, including the medication name, amount, and regimen.
Is your child allergic to any type of medications?*

NoYes
Medication allergies explanations:*
Please list the medication(s) to avoid. This information will be useful to provide if your child requires medical attention.
Medical Conditions: Has your child experienced any of the following:

Asthma/Wheezing/Hay FeverStomach/bowel problemsDiabetes/HypoglycemiaConvulsions/Seizures/EpilepsyFainting spellsThyroid problemsHeart problemsMobility Concerns
Medical Conditions explanation:*
If any above medical conditions are checked, please explain. For example: If your child has asthma, is it exercise induced? What triggers an attack? Is it controlled with medication? What medication, dose and frequencies? Has your child ever been hospitalized for an asthma attack? If yes, how frequently and when was the last admission?
Personal Considerations:
Kairos staff are trained in Christian youth work and basic first aid, but some emotional or behavioral issues may require special awareness from the staff. These details will be shared with only the appropriate adults to properly supervise your child during the event.
Does your child exhibit (now or within the past two years) any of the following?

Sleep-WalkingBed-WettingHome-SicknessSelf-Harm (thoughts or actions)Eating DisorderViolent BehaviorProblems Dealing with EmotionsDisciplinary Problems at Home or at SchoolCare from a Psychiatrist/Therapist/Counselor
Personal Considerations explanation:*
If any above personal consideration items are checked, please explain. These details will be shared with only the appropriate adults to properly supervise your child during the event.
Other Medical: Is your child being treated for any other injury or sickness that you haven’t already indicated above?*

NoYes
Other Medical explanation:*
Please describe any other medical condition that would be helpful for our staff or medical personnel to know. If there is a need to take your child to the hospital the information on this form will be used to assist in giving him/her the best possible care.
Can your child swim?*

YesNo
Part 4 of 4: Parental Consent and Payment
I, the undersigned, being the parent or legal guardian of the participant named above, do hereby consent to the participation of my child in the trip to the above named location.

I am aware of the hazards and risks associated with participation in outdoor activities. I certify that my child has no medical conditions that would exclude him or her from participation in this trip. I am aware that the Sword of the Spirit (the parent corporation of Kairos) carries general liability insurance only, which does not cover medical evacuation and medical treatment for children participating in this activity. Therefore, it is the parents’ responsibility to provide insurance to cover medical evacuation and medical treatment of their children who participate in Kairos activities.

I will not hold Kairos, The Sword of the Spirit, or event staff liable for any injury that may occur to my child while attending the event. I grant permission for routine, non-surgical medical care and for emergency medical and surgical treatment to be secured for my minor child as deemed necessary by the event's supervising adults or any adult they designate as a supervising adult. (Please be sure your emergency contact is accessible during the event at the phone number given to us.)

I acknowledge that my child must abide by the rules established by Kairos and the instructions of Kairos representatives during the event. Any violation of these rules or instructions can lead to my child’s dismissal from the trip. In such a case, I agree to assume the cost of returning my child home and forfeit any right to a refund of pre-paid fees or expenses. I understand that the Trip Leader will notify me before taking any such action.

I authorize the use of images or videos of my child by Kairos for promotional or communications purposes (in group photos, as described in the Kairos Child Protection Policy).
Signature of Parent/Guardian*

Clear
Use your mouse or finger to draw your signature above
Printed Name Parent/Guardian*

First NameLast Name
Today's Date*

MonthDayYear
Kairos Summit 2025 Fee: $400

Check should be written out to:
The Sword of the Spirit

In the memo line write:
"Kairos Summit" along with the names of the people you're paying for.

Mail to:
Attn: Kairos Summit
Kairos
1502 River Terrace
East Lansing, MI 48823
Transportation costs: For those who live near Michigan, we offer transportation with the Kairos vans for an additional $40 (you can add that to your check amount or add it to your cost here if you are paying by credit card).
Payment Preference*

Pay by credit card (this will include a 2.5% processing fee)Pay by check
Paypal Invoice will be sent to your email for this amount:

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Kairos Summit Registration Form

Youth and Guardian Information

Part 3 of 4: Medical Information

Part 4 of 4: Parental Consent and Payment