Youth Encounter Retreat – Leader Registration Name(Required) First Last Indicate which of the following describes you(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY What is Your Age?(Required)What is Your Youth Group Name?(Required)Please indicate which of the following best describes you(Required) Senior Pastor Youth Pastor Youth Leader Chaperone Volunteer What is Your Email?(Required) What is Your Phone Number?Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code All Leaders must undergo a mandatory Cori check. Your consent gives the YE team permission to conduct a Cori check I provide my consent for a Cori check to be conducted I decline to authorize a Cori check Emergency Contact Name(Required) First Last Emergency Phone(Required)Physician Name(Required) First Last Physician Phone(Required)Health Insurance Provider(Required)Health Insurance Policy Number(Required)Please list any Medical Conditions, Allergies, Disabilities or Impairments that should be disclosed to any medical provider should a medical need arise at Youth Encounter Retreat:(Required) NO INDIVIDUAL WILL BE REGISTERED OR ADMITTED TO YOUTH ENCOUNTER RETREAT WITHOUT COMPLETING AND SIGNING THE FOLLOWING. Liability & Medical Release Each adult registrant must sign the release: Having been made aware of the activities that I will be doing; I hereby consent to my participation in YOUTH ENCOUNTER RETREAT. I indemnify, defend and hold harmless Christian Assembly Church & Life Church for all claims and liabilities assessed against them as a result of the activities. Further, in case of emergency, I understand that every effort will be made to contact emergency contacts that I have listed. However, if my emergency contact cannot be reached, or if I, the below signed registrant, am 18 years of age or older, I hereby give the Christian Assembly Church & Life Church and/or group leader permission to act on my behalf in seeking medical treatment in the event that such treatment is deemed necessary or advisable to the my health, safety, and welfare I give permission to those administering medical treatment to do so, using the measures deemed necessary. I release Christian Assembly Church & Life Church and all medical providers from any injury resulting from the activities. RECORDING RELEASE: In registering for YOUTH ENCOUNTER RETREAT 26, I give permission to YOUTH ENCOUNTER RETREAT 26 and its video/audio production staff to use your name, voice, video image and/or photo in future promotional pieces, broadcasts, and the YOUTH ENCOUNTER RETREAT website. I agree to the terms and conditions above:(Required) I agree Signature(Required)YE26 - Leader Admission Price:
