Faith Rocks

Please check appropriate age group

Middle SchoolHigh School
Form to be completed by the participant and parent/guardian

Participant Information:
"FAITH ROCKS" is a 3 day retreat designed to help the youth develop or nurture a relationship with Jesus Christ. They will have an opportunity to join in Christian fellowship through music, sharing, activities, worship and group building exercises. "FAITH ROCKS" is designed for Jr High School through High School age teens. "FAITH ROCKS" is not designed to help solve deep-seated personal problems but to help participants focus on their Christian walk of faith. You should complete, sign the participant form and return to Faith of a Mustard Seed Ministry, INC. via mail with a form of payment no later than two weeks before the event. Make checks payable to "Faith of a Mustard Seed Ministry". The cost of the weekend is $50 if paid by May 31, or $60 if paid June 1 or later. Cost includes food, t-shirt and water bottle. Participants must also submit a consent & liability form as well as an expectant behavior covenant.
Name

First NameLast Name
First Name for Name Tag
Date of Birth

MonthDayYear
Date
Grade Next School Year
Gender

MaleFemale
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

CityState / Province

Postal / Zip Code
School
Church
Shirt size
Youth Leader's Name
Youth Leader's Phone:
Please enter a valid phone number.
Insurance Information
Insurance Company
Name of Responsible Person
Policy #
Group #
Contacts

List only individuals who may be contacted and may assume care of participant.
Mother/Guardian's First & Last Name

First NameLast Name
Employer:
Email
example@example.com
Phone Numbers for Mother/Guardian
Father/Guardian's First & Last Name

First NameLast Name
Employer:
Email
example@example.com
Phone Numbers for Father/Guardian

Medical Treatment Form

Please Complete the Entire Form
List of all allergies:
If none, type "None"
List of all food allergies:
If none, type "None"
List All Special Medical Conditions:
If none, type "None"
Medications, Dosage & Times Taken
List any medical restrictions or anything that would contradict their daily medication:
Does the participant wear contacts?

YesNo
Blood type if known:
Family Doctor:

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.
Doctor's Emergency Number
Please enter a valid phone number.
Family Dentist:

First NameLast Name
Dentist's Phone Number
Please enter a valid phone number.
Dentist's Emergency Number
Please enter a valid phone number.

Part 1

Faith of a Mustard Seed Ministry, INC. Permission for Participation and Permission for Emergency Medical Treatment
I, blanks, the parent/guardian/custodian of blank , give permission for him/her to participate in the Retreat and activities and/or events sponsored by Faith of a Mustard Seed Ministry, Inc., (herein FMSM) from the dates of Date to Date
In the event of injury or illness to my child, I give Faith of a Mustard Seed Ministry, Inc., staff, personnel, and any adult volunteer permission to sign any waiver of liability which may be required to receive medical attention. Further, I authorize the FMSM staff, personnel, adult volunteers and/or any licensed physician, EMT or other qualified hospital personnel to render emergency first aid and/or seek all necessary medical attention and treatment. I understand that in the event my child needs emergency first aid and/or medical attention, FMSM will notify me as soon as reasonably possible.

I am aware of and agree with the “Faith Rocks” rules, and policies of FMSM; the property on which the Retreat is being held; and any activities and/or events held in connection with the Retreat. I understand that a violation or refusal to follow these rules, and policies could result in my child being required to leave the Retreat or activity and/or event related to the Retreat.

Part 2

Faith of a Mustard Seed Ministry, INC. Photo Release and Consent
I give my permission and consent, to Faith of a Mustard Seed Ministry, Inc., (herein FMSM) its officers, employees, agents, assignees, licensees, and cooperating related entities, and their representatives, to use my or my child’s likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like (herein pictures), for any purpose consistent with the FMSM mission. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I and my child release, hold harmless, and forever discharge FMSM its officers, employees, agents, assignees, licenses, and cooperating related entities, their representatives, heirs, and executors from any and all claims, demands, and causes of action, which I and/or my child’s, heirs, executors, representatives, administrators, or any other person acting on my and/or my child’s behalf, or on behalf of my and/or my child’s estate, which they have or may have by reason of this release, consent, and authorization.

Part III

Faith of a Mustard Seed Ministry, INC Waiver of Liability and Release of Claim
IN ORDER FOR ME AND/OR MY CHILD TO PARTICIPATE IN THE RETREAT, ACTIVITIES, AND EVENTS, SPONSORED BY FAITH OF A MUSTARD SEED MINISTRY, INC., HEREIN CALLED “FMSM”, I AND/OR MY CHILD HEREBY, AND FOR (MY) HEIRS, EXECUTORS, ADMINISTRATORS, AND/OR ASSIGNS, WAIVE AND RELEASE ANY AND ALL RIGHTS AND CLAIMS OF ANY NATURE THAT (I OR MY CHILD) MAY HAVE AGAINST FAITH OF A MUSTARD SEED MINISTRY, INC., ITS OFFICERS, EMPLOYEES, AGENTS, ASSIGNEES, LICENSEES, AND COOPERATING RELATED ENTITIES, THEIR REPRESENTATIVES, HEIRS, AND EXECUTORS. I AND MY CHILD FURTHER WAIVE AND RELEASE ANY AND ALL RIGHTS, CLAIMS, AND CAUSES OF ACTION FOR ANY AND ALL INJURIES AND/OR DAMAGES OF ANY KIND AND NATURE, INCLUDING PROPERTY DAMAGE, WHICH (I AND/OR MY CHILD) MAY SUFFER FOR ANY REASON KNOWN AND/OR UNKNOWN, FORESEEN AND/OR UNFORESEEN, WHILE TAKING PART IN ANY ACTIVITIES AND/OR EVENTS CONNECTED WITH THE RETREAT INCLUDING AS THE RESULT OF THE NEGLIGENCE OF FAITH OF A MUSTARD SEED MINISTRY, INC., ITS OFFICERS, EMPLOYEES, AGENTS, ASSIGNEES, LICENSEES, AND COOPERATING RELATED ENTITIES, THEIR REPRESENTATIVES, HEIRS, AND EXECUTORS. THIS RELEASE AND CONSENT SHALL BE BINDING UPON MY AND MY CHILD’S HEIRS, EXECUTORS, ADMINISTRATORS, AND/OR ASSIGNS. BY SIGNING THIS RELEASE, I AFFIRM THAT I HAVE READ AND UNDERSTAND THE WAIVER OF LIABILITY AND RELEASE OF CLAIM FORM.
I, and my child, have read the foregoing document, consisting of two typed pages, in its entirety, and have initialed each page. I understand that my signature affirms that I have read, understand and agree to the terms of the document including the Permission for Participation and Medical Treatment, Photo Release and Consent, and Waiver of Liability and Release of Claim.
Printed name of Parent/Guardian/Custodian

First NameLast Name
Parent/Guardian/Custodian Signature

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Youth Participant Name

First NameLast Name
Parent/Guardian/Custodian Signature

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Emergency Contact Phone Number
Please enter a valid phone number.

Registration Fee

Registration FeeCampers fee

$50.00

Enter coupon

Total

$0.00

Credit Card

Heading
Should be Empty:

Form to be completed by the participant and parent/guardian

Insurance Information

Contacts

Medical Treatment Form

Part 1

Part 2

Part III

Credit Card

Heading