Youth Alive Registration | Living Word Christian Church

Youth Alive 2024 Summer Retreat Registration

Please complete one form for each camper.

Camper Information

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Age(Required)

Date of Birth(Required)

MM slash DD slash YYYY

T-Shirt Size(Required)

Grade Last Completed(Required)

Phone(Required)

Email(Required)

Are you a member of Living Word Christian Church?

Yes

If so, for how long?

Rules Agreement

I have read and understand the rules as stated and agree to abide by them.

● No smoking/vaping, drugs, alcohol, sexual activity, cursing or vulgar language, destruction of property, fireworks, or weapons of any kind. No guys in girls’ room, girls in guys’ room, leaving rooms at night, leaving the camp, skipping services, pranking or hazing, or getting into other people’s belongings.
● Dress Code: We’re not measuring shorts or tank-top straps, but if your clothes are too revealing, you’ll be asked to change. Shorts are acceptable at all times. No two-piece swimsuits, please. If you have clothing questions, please ask before check-in.
● Participation: Your attendance and participation are mandatory at all scheduled events and activities. The more involved you are, the more you’ll get out of the retreat.
● Please do not bring snacks or drinks, (Living Waters Bible Camp does not allow food or beverages (water excluded) in the cabins due to insects), personal music devices, electronic games, computers or tablets, walkie-talkies or 2-way radios, or cell phones. Most cell phones do not receive service at camp because the location is in a valley. If any of these items are brought, they will remain in staff possession for the duration of the retreat. Please use the emergency contact numbers in order to contact the retreat staff or attendees.
● Pictures of retreat attendees may be used in future event publications.
● Violations of these rules, or additional instructions given verbally during the course of the retreat, will result in a verbal warning issued by retreat staff. Continued or further incidents would result in disciplinary action, up to and including dismissal from the retreat.
● Retreat staff decisions are final.

Emergency Contact Information

Emergency Contact #1(Required)

First Last

Relationship(Required)

Email(Required)

Primary Phone(Required)

Secondary Phone

Work Phone

Emergency Contact #2(Required)

First Last

Relationship(Required)

Email(Required)

Primary Phone(Required)

Secondary Phone

Work Phone

Medical Information

Physician(s)(Required)

Hospital Name(Required)

Hospital Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Last Physical Exam:(Required)

MM slash DD slash YYYY

Date of Last Tetanus Shot:(Required)

MM slash DD slash YYYY

General health for the past two years:(Required)

Excellent

Fair

Poor

Do you use tobacco?(Required)

Yes

If so, how recently and to what degree?

Do you now have or have any history of:

Tuberculosis

High Blood Pressure

Diabetes

Surgery

Cancer

Low Blood Pressure

Epilepsy

Typhoid Fever

Heart Trouble

Blindness

Leukemia

Mental Illness

Syphilis

Allergies

Other:

Diabetes Type:

Cancer Type:

Surgery Explanation

Tuberculosis Explanation

High Blood Pressure Explanation

Low Blood Pressure Explanation

Epilepsy Explanation

Typhoid Fever Explanation

Heart Trouble Explanation

Blindness Explanation

Leukemia Explanation

Mental Illness Explanation

Syphilis Explanation

Allergies Explanation

Other Explanation

Surgery Explanation

Please list all medications you are currently taking:

Medical Information Acknowledgement(Required)

I have read, understand, and agree to the following statement:

I, the undersigned, hereby acknowledge that the information provided is truthful and accurate. If emergency or required medical care is needed, I hereby consent to such medical care as deemed necessary by medical care providers and the listed event person in-charge.

Liability Release Information

Liability Release(Required)

I have read, understand, and agree to the following statement:

I, the undersigned, give my full permission for my child/children to attend the event listed above. I hereby waive any and all claims and hold harmless Word of Life Ministries, Inc. aka Living Word Christian Church and any of its employees, staff, members, and/or volunteers of any liability incurred at or as a result of attending the event documented on this form or any act or failure to act by any of the employees, staff, members and/or volunteers of Living Word Christian
Church including but not limited to: damage or loss of/for personal injuries or property damage, travel to the destination, travel from the destination, any travel that may occur on-site or off-site, any injury sustained while serving or working or at any time for any reason during any course of this trip, any natural and/or man-made disaster and/or accident that that may occur during any course of this trip, any sickness and/or illness and/or life threatening condition and/or death. If emergency or required medical care is needed, I hereby consent to such medical care as deemed necessary by medical care providers and the listed event person in-charge.

Signed (Parent/Guardian name if participant is under 18(Required)

First Last

Today's Date(Required)

MM slash DD slash YYYY

Online Registration Payment Quantity

Price: $195.00

Quantity

Pay Online Now

In Person Registration Payment Quantity

Price: $0.00

Quantity

Cash or Checks Accepted in the Church Bookstore

Total

Payment Method

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

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