2024 College Spring Break

Participant Information and Liability Form

First Name *

Last Name *

Date of Birth * +

Address 1 *

Address 2

City *

State *

Zip *

Phone

Email Address *

Allergies (please list)

Medications

Insurance Company *

Insurance Policy Number *

Hospital Preference

Contact Person *

Relationship to you *

Emergency Contact Phone *

In consideration of South Church accepting and permitting me to attend and participate in their activities, I agree that South Church, a non-profit organization, its agents, officers, employees, trustees and volunteers will not be liable for any injury, death, damage and/or loss to me and/or anyone claiming on my behalf, and I further agree to hold harmless, indemnify and defend South Church, its officers, agents, employees, trustees and volunteers for and from any and all damage during the time of my attendance and participation, whether such injury, illness, or damage occurs on or off the church’s premises.

I grant permission to the church representative to have a doctor, if necessary, to administer medicine, treatment and/or anesthetic if I become ill or am injured while at all outings.

I am at least eighteen (18) years of age, and I am under no mental or legal disability which would prevent me from signing and executing this agreement. I further represent that I have read (or have had read to me) and understood the terms of this agreement.

Signature *

clear

Payment options include Deposit, Remainder (if you already paid the deposit) and Full Amount. Unfortunately, we have to pay for these transactions, so there is a 3% fee for each. If you are already signed up, you may use this same registration form again to finish payment. *

Deposit - $100 (103)

Remainder - $350 (360.50)

Full payment for Freshman - $450 (463.50)

Full payment for Non-Freshman - $495 (509.85)

Partial payment ($50/100 scholarship) - $400 (412)

Liability Form Only