SR2 High School Alternative Spring Break

April 19 to 21, 2019

Your Information

Registration

SR2 High School Alternative Spring Break ($60.00)

Note: The Early bird registration ends on Friday, April 5th. After that, the price will increase to $60.

Discount Code

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Gender

Male
Female

Date of Birth

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Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Address

Emergency Contact Information

Parent's Name

Parent's Email

Parent's Cell Phone

Emergency Contact Name

Emergency Contact Cell Phone

Local Church community

Please rank each option with a rank of 1 - 3 so we know what kind of service work you'd prefer. Rate 1 as your most preferred option and 3 as your least preferred option:

Durham Rescue Mission - Serving meals at a homeless shelter

Falls Lake - Cleaning up trash in a state park

Car Wash Fundraise - Wash cars to raise funds for future Youth events

Medical Information

I do not have health insurance
I do have health insurance

Health Insurance Name

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Health Insurance Member Phone Number

Medical ID #

Medical Group #

Policyholder's name

Policyholder's Date of Birth

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Code of Conduct

I will engage and participate fully in the prepared program.
I will adhere to staff instructions and guidance.
I will not engage in any substance related activities (alcohol, recreational drugs, cigarettes, etc) or exclusive romantic relationships.
I will have fun! And help others to have fun!

Print Name (Participant)

Signature (Participant)

I, the undersigned, agree to the terms above.

Waiver

I, Parent/Legal Guardian/Young Adult, do hereby acknowledge that I will release the Holy Spirit Association for the Unification of World Christianity (hereinafter “HSA-UWC”), its officers, directors, staff members, volunteers, advisors, property owners, or agents from any and all claims which may hereafter develop or accrue to them on account of injury, loss or damage, which may be suffered by said child/children or to any property, because of any matter, thing, or condition, negligence or default whatsoever, in connection with the SR2 High School Alternative Spring Break on April 19-21, 2019 (“Workshop”).

I hereby assume and accept full risk and danger of any hurt, injury or damage that may occur through or by reason of any matter, thing or condition, negligence or default, or any person or persons whatsoever.

I authorize medical treatment for my child/children/individual in case of accident or illness during or in relation to his/her/their participation in the Workshop and will be responsible for all the expenses and charged incurred thereof.

I have carefully read this Parent/Legal Guardian/Young Adult Waiver Form and fully understand its contents. By signing and/or agreeing to this document, I agree to its terms.

Print Name (Parent/Legal Guardian/Young Adult)

Singature (Parent/Legal Guardian/Young Adult)

I, Parent/Legal Guardian), _______________________________________________, do hereby acknowledge that I will release the Holy Spirit Association for the Unification of World Christianity (hereinafter “HSA-UWC”), its officers, directors, staff members, volunteers, advisors, property owners, or agents from any and all claims which may hereafter develop or accrue to them on account of injury, loss or damage, which may be suffered by said child/children or to any property, because of any matter, thing, or condition, negligence or default whatsoever, in connection with the Peace Starts with Me Workshop on November 10-12, 2018 (“Workshop”). I hereby assume and accept full risk and danger of any hurt, injury or damage that may occur through or by reason of any matter, thing or condition, negligence or default, or any person or persons whatsoever.

I authorize medical treatment for my child/children in case of accident or illness during or in relation to his/her/their participation in the Workshop and will be responsible for all the expenses and charged incurred thereof.

I have carefully read this Parent/Legal Guardian Waiver Form and fully understand its contents. By signing and/or agreeing to this document, I agree to its terms.

I, the undersigned, agree to the terms above.

Total

$60.00

For questions please email Josh Angelucci ([email protected])

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