Individual Registration

Select your Church or Organization
PERSONAL INFORMATION
At the time of your trip, will you be over the age of 18?(Required)*

YesNo
Date of Birth

MonthDayYear
Age
Participant Name*

First NameLast Name
Phone Number*
If you do not have a phone number simply put (111) 111 -1111
Email (Required)*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender(Required)*

MaleFemale
What Church, Organization, or Group will you be attending with?*
please have your trip coordinator contact us to schedule a trip first.

MEDICAL INFORMATION
Emergency Contact

First NameLast Name
Emergency Contact Phone #
Please enter a valid phone number.
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List any medical conditions/allergies we should be aware of:
List any medications you are taking:

If you are 18 years or older, you may select "Next" to skip this section.
PARENT OR GUARDIAN INFORMATION
Parent or Guardian Full Name

First NameLast Name
Parent or Guardian Email
*This email MUST be different from the minor participant email.
Parent or Guardian Phone Number
Please enter a valid phone number.
* This must be contact information for your Parent or Guardian
PARENTAL CERTIFICATION, CONSENT AND RELEASE

Minor Participant
I,Parent/Guardian Name*, am the parent or legal guardian of   Participant Full name*         who was born on     Participant's DOB*   .

I warrant that I possess all the rights, powers, and privileges of a parent or legal guardian necessary to execute this legal instrument with binding legal effect.

As a parent or legal guardian of * {participantName}, I certify and affirm that I have been completely and thoroughly informed that as a youth attending Dream Center of Philadelphia, my child will participate in certain activities that carry with them a degree of risk and danger.
Examples of risky and dangerous activities include, but are not limited to:
- Physical activities, both indoors and outdoors
- Sports, both informal and organized
- Use of recreational equipment
- Street Evangelism, including but not limited to engaging in conversations, passing out flyers, distributing water/food
- Ministry, both on and off campus
- Travel by automobile or walking to/from housing and the Outreach ministry sites
- Activities in low-income areas
- Evangelizing in poor areas
- Construction and maintenance projects including, but not limited to assemblies, painting, landscaping, and general cleaning activities.
I acknowledge and understand that The Dream Center may offer other activities. I acknowledge and understand that this PARENTAL CERTIFICATION, CONSENT AND RELEASE has the same force and effect regardless of whether the activities engaged in are free or if a fee is charged.*

I acknowledge and understand that The Dream Center may offer other activities. I acknowledge and understand that this PARENTAL CERTIFICATION, CONSENT AND RELEASE has the same force and effect regardless of whether the activities engaged in are free or if a fee is charged.Further, I personally assume, on my child’s behalf, all risk in connection with said activities for any harm, injury, or damages that may befall my child as a result of my child’s participation in the activities, whether foreseen or unforeseen, and I still wish to allow my child to proceed with the activities.I acknowledge and agree that Dream Center of Philadelphia shall not be held liable in any way for any occurrence resulting directly or indirectly from these activities that result in injury, death, or any other damages to my child, me, or my family, heirs, or assigns. In consideration of my child being allowed to participate in these activities, on behalf of my child, I hereby personally assume all risk in connection with said activities, for any harm injury, or damage that may befall my child, me, or my family, heirs, assigns while engaged in such activities.I understand that the terms herein are contractual and not mere recital; I have signed this document as my own free act. It is my intention by signing this document to exempt and release Dream Center of Philadelphia from all liability whatsoever for personal injury, property damage, or wrongful death caused by negligence.I further acknowledge and agree that my signature on this PARENTAL CERTIFICATION, CONSENT AND RELEASE shall constitute a bar to any recovery by my child, me, or my family, heirs, or assigns in all suits and actions that may be instituted against Dream Center of Philadelphia its agents, servants or employees for injuries or death to my child, whether or not same resulted for the negligence of Dream Center of Philadelphia, its agents, servants, or employees, or due to the contributory negligence of my child.I understand that it is my obligation to inform the management of The Dream Center of Philadelphia of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities involving The Dream Center of Philadelphia or its programs.
I certify that I am the legal parent or guardian of the minor named above and I am completing this form on their behalf.
Parent/Guardian Name
Parent/Guardian Signature

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Assumption of Risk
(Must be signed by every volunteer in your group prior to participating in any activity at the Dream Center)

Note: This is intended for all adults participating as Missionary-Volunteers for the Dream Center of Philadelphia. Since the Dream Center of Philadelphia cannot adequately supervise all Missionary-Volunteer activities, we ask that Missionary-Volunteers assume all associated risks as a condition of their participation.
I, {participantName} , in consideration of my acceptance as a missionary-volunteer of Dream Center of Philadelphia, PO Box 3732 Philadelphia, PA, 19125, represent and agree that:
1. Volunteer Status
  I understand and acknowledge that I am participating as a volunteer worker and not as an employee of Dream Center of Philadelphia.
2. Awareness of Risks
  - I acknowledge that I am aware of the various hazards and risks associated with serving in a missionary capacity, which may include, but are not limited to, risks of death, injury, or illness due to accidents, disease, war, terrorist acts, adverse weather conditions, inadequate medical services, criminal activities, and random acts of violence.
    
    Examples of risky and dangerous activities include, but are not limited to:
    
    Physical activities, both indoors and outdoors
    
    Sports, both informal and organized
    
    Use of recreational equipment
    
    Street Evangelism, including but not limited to engaging in conversations, passing out flyers, distributing water/food
    
    Ministry, both on and off-campus
    
    Travel by automobile or walking to/from housing and the Outreach ministry sites
    
    Activities in low-income areas
    
    Evangelizing in poor areas
    
    Construction and maintenance projects including, but not limited to assemblies, painting, landscaping, and general cleaning activities.
  - I accept my assignment as a Missionary-Volunteer with full awareness of these risks. Subject to any insurance coverage that may be available to me from any source, I voluntarily assume all risks of death, injury, and illness, as well as any potential damage to my personal property.
  - I hereby release Dream Center of Philadelphia, including its agents, volunteers, interns, officers, directors, and employees, from any liability arising from any death, injury, illness, or property damage that may occur as a result of my participation in the missions’ project.
  - I further acknowledge that these risks have historically been associated with missionary service, as referenced in 2 Corinthians 11:23-28.
3. Medical Certification
  I certify that I do not have any medical conditions that would prevent me from performing my duties as a Missionary-Volunteer.
4. Legal Binding Obligation
  I expressly waive any defense to the enforcement of any provision of this agreement on the basis of lack of consideration and warrant that this agreement constitutes a legally valid and binding obligation, enforceable against me in accordance with its terms.
5. Insurance Acknowledgment
  - I understand and acknowledge that participation in activities as a Missionary-Volunteer with Dream Center of Philadelphia may involve hazards and risks, as outlined above.
  - I also understand that Dream Center of Philadelphia may not provide insurance coverage in the event of my death, illness, injury, or damage to my property during my participation as a Missionary-Volunteer.
  - If I desire insurance coverage, I acknowledge that it is my sole responsibility to obtain and bear the cost of such insurance.
6. Scope of Agreement
  I agree that this Assumption of Risk and Release of Liability Agreement is intended to be as broad and inclusive as permitted by law and shall be governed by the laws of the Commonwealth of Pennsylvania.
Acknowledgment of Understanding

I affirm that I HAVE CAREFULLY READ AND FULLY UNDERSTAND the contents of this CONSENT AND RELEASE by reading it before I signed it.I acknowledge that this is a legal document and I have the opportunity to consult with an attorney before signing it.
Participant Full Printed Name*
Date*

MonthDayYear
Date
Signature*

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Media Release
I, the undersigned, hereby grant permission to the Dream Center of Philadelphia to use my and/or my child’s story, photo, or other content (hereinafter referred to as “Materials”) for use on the Dream Center of Philadelphia’s website, social media platforms (including but not limited to Twitter, Facebook, and Instagram), and printed materials.

I release the Dream Center of Philadelphia and its representatives, employees, managers, members, officers, parent companies, subsidiaries, and directors from any and all claims or demands arising from or related to the use of these Materials, including but not limited to claims of invasion of privacy, violation of publicity rights, defamation, or any other personal or property rights.

I acknowledge and agree that I will receive no compensation for the use of the Materials, unless otherwise agreed to in writing.
Please choose ONE of the following*

I am filling this release out for myself.I am filling this release out for my child, who is a minor.I am filing this release out as a representative for a group and I have authority to do so.
Please select one of the following options to grant permission for the use of your image in the following ways:*

Unrestricted usage: I grant full permission for my image to be used in print, video, and digital media. I understand that these images may be utilized by the Dream Center of Philadelphia for various purposes and may be used without further notification.Limited usage: I consent to my image being used solely on printed materials (no digital or video usage).Deny Permission: I do not consent to the use of my/child's image or my/child's name in any form.
Print Name*
Date
Signature*

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Code of Conduct
As a follower of the Lord Jesus, our conduct should be a witness to others of a transformed life. Paul wrote to Titus, “And show your own self in all respects to be a pattern and a model of good deeds and works, teaching what is unadulterated, showing gravity (having the strictest regard for truth and purity of motive), with dignity and seriousness. And let your instruction be sound and fit and wise and wholesome, vigorous and irrefutable and above censure, so that the opponent may be put to shame, finding nothing discrediting or evil to say about us” (Titus 2:7-8, Amplified Bible, emphasis added).
Initials*
As a Philadelphia Dream Center Urban Missions Team Member, I realize the important role I serve as an example to those in Philadelphia, PA. I understand that I represent not only my local church but also the Dream Center and most importantly, Jesus Christ. In respect to this assignment, I will refrain from anything (e.g., alcohol, tobacco, unwholesome speech) that may distract from my Christian testimony, cause division, or demonstrate disrespect to my team members, the Dream Center, or the Kingdom of God. I will also make sure to follow all rules set forth by my leaders and Pastors. I promise to forgo my personal convictions on these subjects to maintain unity and avoid controversy in the body of Christ.
Initials*
I affirm that I do not have any criminal convictions or allegations related to sexual misconduct with adults or minors, nor do I know of any reason I should not be allowed to work with adults or minors as an Urban Missions Experience volunteer.
Initials*
Acknowledgment of Understanding

I affirm that I HAVE CAREFULLY READ AND FULLY UNDERSTAND the above policy And agree to comply with the standards that have been set forth.
Printed Name
Date

MonthDayYear
Date
Signature

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Should be Empty:

PERSONAL INFORMATION

MEDICAL INFORMATION

If you are 18 years or older, you may select "Next" to skip this section.

PARENT OR GUARDIAN INFORMATION

* This must be contact information for your Parent or Guardian

PARENTAL CERTIFICATION, CONSENT AND RELEASE

If you under 18 years old, you may select "Next" to skip this section.

Assumption of Risk

If you under 18 years old, you may select "Next" to skip this section to complete the Code of Conduct.

Media Release

Code of Conduct