2025 ABT Rooted and Rising Bus Trip Participant Registration

For youth participants who will be 14-19 years* of age by December 31, 2025.

* PHTL (Primary Home Team Leaders) may apply for age exceptions prior to registering youth by contacting Tammy Kirkwood (TammyStPauls@gmail.com) or Krystle Plant (raiynisawall@hotmail.com).

***Please be advised: Registration for the Gathering is separate from this registration. Information can be found at www.claygathering.ca. The gathering begins the evening of Thursday, August 21, 2025, at 3:30 pm and concludes Sunday, August 24, 2025.

PARTICIPANT REGISTRATION FORM

Full Name

First NameLast Name

Preferred Name

Birth Date

MonthDayYear

Gender

Name of Parent or Guardian

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

Cell Phone Number

Area CodePhone Number

Sizing for T-Shirt (Unisex)

Home Congregation/Parish Name

Congregation/Parish Location

Congregation/Parish Phone

Area CodePhone Number

Synod/Diocese

I am a Member of

Emergency Contact Information:

Please provide the following information for your Emergency Contact Person (ECP)

Name of Primary Contact

First NameLast Name

Relationship

Phone

Area CodePhone Number

Night time phone (if different from day time)

First NameLast Name

Secondary Contact

First NameLast Name

Secondary phone

Area CodePhone Number

Relationship

Medical Information:

Health Care Number

Doctor

Phone

Do you have food allergies?

List allergies

Anaphylactic?

Other dietary requirements

Dietary details

Comments (if necessary)

Please note: all dietary requirements must be identified on the registration form. No late/additional arrangements will be made at the event.

Do you have other relevant health concerns?

If yes, list type or care requirements

Physical Disabilities - do you require assistance? If so, specify here

CONSENTS - to be completed by participants 18 years or older or by guardians of younger participants

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:

I understand that my/my child's name and photograph may be used as the result of their attendance at the 2025 ABT Synod CLAY Pre-Trip and I consent to the ABT Synod Planning Committee and/or its representatives to the use of same.

I consent that the ABT Synod 2025 Bus Trip Planning Committee and/or its representatives may seek medical attention for me/my child during the 2025 Bus Trip, and hereby authorize it to consent to, on me/my child's behalf, for any medical procedure which may be recommended by a medical practitioner. It is understood that every attempt will be made to notify the next of kin or emergency contact person in the event that such action needs to be taken.

I have reviewed the information set out in the participant registration form and certify that it is correct and accurate in all respects. I hereby provide my authorization and consent for me/my child to attend the 2025 ABT Synod CLAY Pre-Trip.

The Synod of Alberta and the Territories and the ELCIC are committed to protecting the privacy of the personal information submitted to it by youth and parents who are registering for events. The information that you provide will be used for purposes internal to the Synod of Alberta and the Territories and the ELCIC for which such information in provided. Personal information will not be shared with third parties without your expressed consent. The information that you provide will be protected and retained in accordance with the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Privacy Policy of the ELCIC. Further information on this policy can be viewed on the ELCIC website: www.elcic.ca

Signature

ABT Synod 'Rooted and Rising' Bus Trip