GLS2026
OCTOBER 15-16 PLACE OF GRACE 252 SCHOOL ST. ROCKINGHAM, NC 28379
PARTICIPANT INFORMATION
Full Name
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First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I would like to stay on the Place of Grace Campus. (There is not charge for this, but a donation to POG is recommended.
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Yes, I want to stay on campus
No, I will take care of my own lodging
PARTICIPANT AGREEMENT AND CONSENTS
Please read each section carefully. By signing below, you confirm that you understand and agree to the required provisions.
PARTICIPANT ELIGIBILITY
I confirm that I am at least 18 years old. If I am under 18, a parent or legal guardian must complete and sign the Parent/Guardian Consent section.
*
I confirm
ASSUMPTION OF RISK
I understand that participation in the Go, Love, Serve Trip 2026 may involve risks, including travel; walking, lifting, and other physical activity; unfamiliar locations or conditions; interactions with other participants and members of the public; illness; accidents; bodily injury; property damage; and other risks that may not be foreseeable. I voluntarily choose to participate and knowingly accept the ordinary and inherent risks associated with the trip and its activities. I agree to follow all safety instructions and immediately notify a trip leader if I become aware of an unsafe condition or if I am unable to participate safely.
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I have read, understand, and voluntarily accept the risks described above.
RELEASE OF LIABILITY
To the fullest extent permitted by applicable law, I release and hold harmless the CONGREGATIONAL HOLINESS CHURCH WORLD MISSIONS and its directors, officers, employees, volunteers, trip leaders, agents, and representatives from claims arising from the ordinary and inherent risks of my voluntary participation in the trip.This release does not apply to claims that cannot legally be waived, including liability that applicable law does not permit the organization to exclude.
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I have read and agree to the Release of Liability.
EMERGENCY MEDICAL AUTHORIZATION
If I experience an illness, injury, or medical emergency and I am unable to provide consent, I authorize the CONGREGATIONAL HOLINESS CHURCH WORLD MISSIONS, its trip leaders, and its designated representatives to contact emergency services and arrange reasonably necessary medical care on my behalf.I understand that trip leaders are not medical professionals and cannot guarantee the availability or outcome of treatment. I accept responsibility for medical expenses incurred on my behalf except where applicable law provides otherwise.
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I authorize emergency medical assistance as described above.
EMERGENCY CONTACT INFORMATION
Name of Emergency Contact
*
First Name
Last Name
Relationship to Participant (parent, spouse, sibling, guardian, etc.)
*
Phone Number
*
Format: (000) 000-0000.
Health Insurance Provider
Health Insurance Policy or Member Number
MEDICAL AND ACCESSIBILITY INFORMATION
Please disclose information that trip leaders would reasonably need to respond to an emergency or support your safe participation. Do not include unrelated medical history. IF YOU DO NOT HAVE ANY MEDICAL, DIETARY, OR ACCESSIBILITY ISSUES, ENTER "NONE" OR "DOES NOT APPLY"
ALLERGIES
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DIETARY RESTRICTIONS
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MEDICATIONS OR MEDICAL INFROMATIOIN RELEVANT TO EMERGENCY CARE
*
PRIVACY NOTICE AND MEDICAL-INFORMATION AUTHORIZATION
THE CONGREGATIONAL HOLINESS CHURCH WORLD MISSIONS collects the information submitted through this form to: • Register and communicate with participants • Plan and administer the trip • Address dietary and accessibility needs • Support participant safety • Contact emergency personnel or emergency contacts when reasonably necessary • Meet applicable legal, insurance, or recordkeeping obligations Access will be limited to authorized staff, volunteers, trip leaders, service providers, emergency personnel, and others who reasonably need the information for these purposes. Relevant information may be shared when reasonably necessary to protect health or safety or when required by law.The organization will take reasonable measures to safeguard this information and will retain it only for [retention period] or as otherwise required by law. Questions, correction requests, and deletion requests may be directed to: JONATHAN FITZPATRICK - 770-228-4833 or email jonathan@chchurch.com
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I have read and understand the Privacy Notice.
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I authorize the organization to share relevant allergy, dietary, medical, and accessibility information with authorized trip leaders, emergency personnel, medical providers, and service providers when reasonably necessary for my safety, accommodation, or participation.
PHOTO AND MEDIA PERMISSION
I understand that declining media permission will not affect my eligibility to participate. I may withdraw permission for future uses by contacting general@chchurch.com, but withdrawal may not apply to materials already published or distributed.
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YES. I give CONGREGATIONAL HOLINESS CHURCH WORLD MISSIONS permission to photograph or record me during the Go, Love, Serve Trip 2026 and to use my image, voice, or likeness in organizational communications, websites, social media, newsletters, reports, and promotional materials without compensation.
NO. I do not give permission for identifiable photographs or recordings of me to be used for these purposes.
ACCURACY AND ELECTRONIC SIGNATURE
By signing below, I confirm that:• I have read this Participant Agreement and had an opportunity to ask questions• The information I provided is accurate and complete to the best of my knowledge• I agree to notify the organizer if relevant information changes before the trip• I intend my electronic signature to have the same effect as my handwritten signature• I understand that submitting this form creates an electronic record of my agreement
Participants Legal Full Name
*
First Name
Last Name
Participant, Parent, or Legal Guardian Signature
*
Submit
Submit
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