Remnant Westside Church

College Retreat 2009 Registration

Theme: City on a Hill: Authentic Biblical Communities
Speaker: Pastor Mark Chun, Kairos Christian Church
Location: Taconic Retreat & Conference Center
Dates: October 8-11, 2009

Regular Registration: $80
September 6 — September 27
Late Registration: $95
September 28 — September 4
Early bus: Thursday, October 8th at 7:00pm
Late bus: Friday, October 9th at 7:00pm
Super late bus: Friday, October 9th AFTER 7:00pm
Please indicate the earliest time you can leave in the notes.

First Name: Last Name: Gender: Male Female Email: Phone: Date of Birth (click and select a date): Campus: Year Transportation: Taking the Thursday 7:00pm bus Taking the Friday 7:00pm bus Taking the late Friday bus (indicate earliest departure time in the notes on the right)

Emergency Contact Name: Emergency Contact Telephone: Medical History: Special Dietary Concerns: Notes (any other info to submit with your registration):

Release Statement

I hereby release Remnant Westside Church, its officers, employees, agents, and members of the Board of Elders from all claims and causes of action by reason of any injury which may be sustained as a result of these church activities, whether on the church premises or on the way to or from these activities. I agree to cooperate and conform with directions and instructions of personnel of the organization in charge of these activities. On the account that I do not, I understand that I may be sent home and will be responsible for additional expenses that may incur.

I hereby give my permission to the physician, nurse, or dentist selected by Remnant Westside Church to secure medical or dental aid as required for illness or injury under a physician’s orders, including transportation to and from necessary facilities. As a participant, I understand Remnant Westside Church is not obligated to carry any insurance to cover those medical and/or dental expenses. If such insurance is carried, coverage will be provided only for expenses in excess of the limits of the participant’s insurance. I understand that my personal insurance is my primary coverage.

This authorization shall remain effective until revoked in writing delivered to Remnant Westside Church.