New Life Northwest Adult Registration

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthday

Date

Shirt Size

Name Of Church Attending With

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Insurance Provider

Policy Number

Are You Currently Taking Any Medication(s)? If Yes, Please List All Medication(s).

Are You Allergic To Any Medications? If Yes, Please List All Medication(s).

Do You Have Any Other Allergies Or Sensitivities? If Yes, Please List All Other Allergies Or Sensitivities.

We Will Have GLUTEN FREE And DAIRY FREE Options At Each Meal, Please Select All Options You Will Need

Housing Arrangements:

Medical Consent:
I, the undersigned, do hereby authorize any member of the NLNW staff as
an agent for the undersigned to consent to any X-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act.
It is understood that this authorization is given in advance of any specific diagnosis,
treatment, or hospital care being required but is given to provide authority and power on the part of the aforesaid agent to give specific consent to any and all such diagnosis, treatment, or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. Every effort will be made by the staff to notify the designated family contact before any action is taken. This authorization shall be in effect from August 2-7, 2026.
Signature* First Name* Last Name*

Liability Release and Consent:
I have voluntarily applied to participate in this church-sponsored program. I
understand that there are risks in my and my family's presence, transportation, and
participation in this church-sponsored program. I hereby agree on behalf of myself and my family to assume any and all risk of bodily injury, death, or property damage, arising out of, or caused by myself or my families presence and participation in the church-sponsored program. I hereby release the church and any of its affiliated organizations, agents, or employees, from all actions or claims that myself or my families, our heirs and/or legal representatives now have or may hereafter have for bodily injury, death, and property damage resulting from myself or my families participation in this church sponsored program. I have carefully read this agreement and am aware that this is a release of liability and contract between myself and NLNW Family Camp and by submitting this form, I am signing it of my own free will.
Signature* First Name* Last Name*