Clone of Fall Elementary Retreat 2025 Adult Registration Form

Living RiverFall Elementary Retreat 2026- Adult Information Form

Thank you for agreeing to chaperone or for volunteering for the Fall Elementary Retreat 2026 at Living River! Without you, the retreat wouldn't bee possible! Your efforts and presence will impact the campers more than you might realize. Pressing the "back" button of your browser will reload the form, so only use the "back" and "next" buttons at the bottom of the form pages. Once you click "submit" you cannot go back to edit your submission, but the "save" option is great if you need to take a pause in filling out the form. A copy of your submission should be emailed to you. There is a separate form for adult chaperones. Thank you! We're looking forward to the Fall Elementary Retreat! Email office@livingriver.org with any questions.
Legal Name:

First NameLast Name
Name You Prefer to be Called:
Birth Date

MonthDayYear
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Church Attending With? Or, select N/A if coming apart from a church group. Please communicate with Living River if attending apart from a church group.
Adult Camper Emergency Contact Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Adult Camper Medical Information

Please answer all questions completely.
Do you have any allergies? If yes, please describe.
Do you have any dietary restrictions? If yes, please describe.
Do you have any chronic illness or condition? If yes, please describe.
Are you prescribed an epinephrine injection device (EpiPen) or any other medication the staff should know about in case of emergencies? If yes, please explain any instructions. *If you require an EpiPen, please bring 2 non-expired EpiPens, one to remain with you and one to keep in your cabin.
Who is your primary health care provider? (In case of emergency)
Provider's Phone Number:

Insurance Information
Medical Insurance Company
Contract Holder Name
Group #
Contract #
Upload a copy or take a picture of your insurance card below:
Upload a picture of your insurance card -OR-

Browse Files

Cancelof
Take a photo of the front of your card.

Living River Consent Agreements

Living River's Medical and Liability Releases are required for participation and for submitting this form. If for some reason, you cannot accept the releases, please email office@livingriver.org. Payment for all participants, child and/or adult chaperones, will be handled through each congregation or through PayPal invoicing if attending apart from a congregation.
Photos/Publicity

I understand that photos of my child or me may be used by Living River for publicity purposes in print or on social media. Names will not be printed. If I do not wish photographs of my child to be used in this capacity I will notify staff, in writing, before the beginning of the camp session.
Please Select:
Living River: A Retreat on the Cahaba, Inc. Participant Release of Liability and Assumption of Risk Agreement

In consideration of being allowed to participate in any way in the program, related events and activities, I the undersigned, acknowledge, appreciate, and agree that:

1. The risk of injury from activities involved in this program is significant, including the potential for permanent paralysis and death.

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation.

3. I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS LIVING RIVER: A RETREAT ON THE CAHABA INC., its officers, officials, agents and/or employees, other participants, volunteers, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any ILLNESS, INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law.

5. I will abide by all local, state, and federal guidelines or laws.

For Adult Participants 18 and Over- I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Please Select:
Your electronic signature below affirms the validity of the information on this form and is equally as binding as an original, manual signature. Your signature applies the above consent releases to every camper you have registered.
Signature
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Living RiverFall Elementary Retreat 2026- Adult Information Form

Adult Camper Emergency Contact Information

Adult Camper Medical Information

Insurance Information

Living River Consent Agreements