MT ZION YOUTH EVENTS REGISTRATION FORM

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HIGH SCHOOL BOY'S BACKPACKING TRIP REGISTRATION FORM

Mt Zion High School Boy's Backpacking Trip Registration Form

1st Student's Name *

First

Last

1st Student's Birth Date *

1st Student's Grade Level for 2023-2024 School Year *

Health Records for High School Backpacking Trip

Please List Allergy Information *

Please describe how the allergy happens, what happens, and what should be done to treat the allergy.

Please List any Health Problems or Medical Conditions Below

Description of Current Medications student is taking (prescription and non-prescription) ONLY IF IT WILL NEED TO BE BROUGHT TO EVENT *

Please describe the name of the medicine, the reason for the medicine, how much medicine is to be taken, and what time the medicine is to be taken.

Insurance Company *

Should you have no insurance provider, please indicate “none”

Name of Insurer *

Should you have no insurance provider, please indicate “none”

Policy Number *

Should you have no insurance provider, please indicate “none”

Would you like to sign-up a second student? *

Total Cost for Backpacking Trip Registration for Students 1 is $90.00

PARENT INFORMATION

Parent Name *

First

Last

Address *

City *

State *

Zip Code *

Primary Phone *

Mom's Cell Phone

Dad's Cell Phone

Email Address *

Alternate Email Address

Do You Attend Mt. Zion Church *

MT ZION YOUTH EVENTS WAIVER (REQUIRED)

In consideration of being allowed to participate in any way in Mt. Zion related events and activities, I, the undersigned acknowledge, appreciate, and agree that: The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown. EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, 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; and, The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during this activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by Mt. Zion or its agents, employees, volunteers, or any other representatives. Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless Mt. Zion for any injury arising directly or indirectly out of this activity or transportation to and from the activity, whether such injury arises out of the negligence of the Mt. Zion, the participant, or otherwise. This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases, and, for myself, my heirs, assigns, and next of kin. I release and agree to indemnify the Releases from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES to the fullest extent permitted by law. 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. SIGN BELOW *

PAYMENT INFORMATION

I understand to confirm my registration and event enrollment requires Mt. Zion to receive my payment in full (cash, Zelle, or check only), to receive a signed waiver, and to receive full insurance information. Choose between the options below to submit payment:

Payment Method (Choose One) *

Drop off at Mt Zion Reception Desk from 9am to 5pm on Mondays – Fridays
Pay with Zelle to events@mtzion.org with a memo stating “High School Boy’s Backpacking Trip”
Give to Pastor Billy, Sam O’Berry, or Gabriel Carnell at any service, class, or event.

Be sure to check your email for information regarding the Youth events.

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MT ZION YOUTH EVENTS REGISTRATION FORM

Mt Zion High School Boy's Backpacking Trip Registration Form

Health Records for High School Backpacking Trip

2nd Student

Health Records for High School Backpacking Trip for Second Student

Total Cost for Backpacking Trip Registration for Students 1 is $90.00

Total Cost for Backpacking Trip Registration for Students 2 is $90.00

PARENT INFORMATION

MT ZION YOUTH EVENTS WAIVER (REQUIRED)

PAYMENT INFORMATION

I understand to confirm my registration and event enrollment requires Mt. Zion to receive my payment in full (cash, Zelle, or check only), to receive a signed waiver, and to receive full insurance information. Choose between the options below to submit payment:

Be sure to check your email for information regarding the Youth events.