Please Make a Copy for Each Participant

Please make a copy for each participant Westminster Woods Work Weekend 2009 November 20-22 Registration Form

Return to church and mail forms to: Presbytery of Southern Kansas Youth Council C/O Kelly Whitesell 1350 S. Lark Lane Wichita, KS 67209

Name: ______

Address: ______

City/State/Zip: ______

Phone & e-mail: ______

Grade Level: 6 7 8 9 10 11 12 Adult

Gender: Male Female

Church: ______

Special Dietary/Medical Needs: ______

______

Designated Adult Sponsor at Event (adult must also be attending event):

______

Please read and sign the covenant below:

In accordance with God’s will for me, I agree to participate and listen for His word as presented at the Westminster Woods Work Weekend. I agree to follow all rules set forth by the Presbytery of Southern Kansas Youth Council during the event. I agree to not engage in any destructive, illegal, or immoral behaviors during the duration of the retreat. I agree to fully participate to the best of my ability in all parts of the event. I agree to stay within the announced boundaries of the camp and to not leave the event without an adult who has spoken to the designated youth council contact person. I understand that Westminster Woods is a nonsmoking area and will follow accordingly. I agree to abide by all other Westminster Woods rules as announced at the event. I agree to refrain from bringing any illegal drugs, alcohol, tobacco, or weapons and to only engage in “event appropriate” displays of affection.

I agree to help make this event one where God’s presence is allowed to flourish. I agree to try and make new friends, renew old friendships, work as a team, and to have a great time. Signature of Participant: ______

Printed Name of Participant: ______For Youth Participants Parent/Guardian Consent/Release Form (Including Emergency Medical Treatment)

Concerning: ______(full name of minor) Date of Birth: ______

This is to certify that my relationship to the above-named minor is: (check as applicable) _____ One of 2 custodial parents, and I have the authorization of the other parent to sign this consent/release form. _____ I am the sole custodial parent. _____ I am the legal guardian.

Concerning this minor: Disabilities/Allergies: (enter “none” if so) ______

Current Medications: ______

Family Doctor’s Name and Telephone: ______

Medical Insurance: ______Policy Holder: ______

Policy number: ______Insurance phone #: ______

Any medical condition that would keep this minor from participating in the event? ______

Emergency Contact – Name: ______Phone: ______

For minor pain/headache, my child may be given (please initial applicable response): Acetaminophen ____ Ibuprofen ______I hereby consent that the above named minor may participate in the following activity: Presbytery of Southern Kansas Youth Event: Westminster Woods Work Weekend November 21 – 23, 2008.

I further consent and authorize that if, at the sole discretion of the Presbytery of Southern Kansas Youth Council’s Adult members Laura Hodson, Kelly Whitesell, Tammi Schulte, Matt Schaffner, Seth Svaty or Don Bromlow, the named minor is in need of emergency medical treatment during the period above noted, I hereby release, and agree to indemnify and hold harmless (1) Such adult (or adults) as a result of signing such consent, (2) the Presbytery of Southern Kansas, (3) Westminster Woods, and (4) all medical personnel providing such medical treatment to said minor during said period for any claims alleged to have arisen out of such participation or such treatment (in the absence of gross negligence or willful misconduct).

In confirmation of the above, I sign this Consent and Release this ______day of ______, 2009.

Printed Name: ______Signature: ______

Address: ______

Phone # during event: ______

Cell Phone or Pager (including area code): ______