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Winter Retreat


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Winter Retreat

Winter Retreat is an opportunity for students of Northwest Youth to get away and focus on becoming better leaders so we can each influence our worlds.


Pricing:

Limited spots are available on a first-come, first-served basis.
Registration is not confirmed without full payment
Price: $175 due by February 1


ASSUMPTION OF RISK, RELEASE, & INDEMNITY AGREEMENT FOR MINORS 18 AND UNDER
Parents or legal guardians of minor children are required to complete this form. This form is NOT valid if completed by the child traveling. This form must be signed by the parent(s) or legal guardian(s) of the minor to be valid. The information requested is designed to assist Northwest Assembly of God (Northwest AG) in providing for the safety of minors during Northwest AG sponsored activities.
FAMILY INFORMATION
Minor's Name *
Minor's Name
Date of Birth *
Date of Birth
Address *
Address
Phone of Student
Phone of Student
Gender *
Name of Parent / Legal Guardian *
Name of Parent / Legal Guardian
Phone of Parent / Legal Guardian *
Phone of Parent / Legal Guardian
Name of Emergency Contact *
Name of Emergency Contact
Phone of Emergency Contact *
Phone of Emergency Contact
MEDICAL INFORMATION
Name of Family Doctor *
Name of Family Doctor
Phone of Doctor *
Phone of Doctor
Is your child presently being treated for injury / sickness or taking any form of medication? If yes, explain. *
Does your child require a special diet? If yes, explain *
Does your child have any physical conditions or illness that would prevent him or her from participating on this trip / event? If yes, explain. *
Does your child have (or ever had) any medical conditions that could require special attention? If yes, explain. *
Are there any activities that you would not want your child to participate in? If yes, explain. *
Medical Treatment Authorization *
I / We, the parent(s) and / or legal guardian(s) of Child, understand that we will be notified in the case of a medical emergency involving the Child. However, in the event that we, or either of us, cannot be reached, we authorize the calling of a doctor and the providing of necessary medical services in the event the Child is injured or becomes ill. We authorize the temporary guardian or any leader on this trip / event to make emergency medical care decisions on behalf of our Child, if required by law or a health care provider. I / We, the parent(s) and / or legal guardian(s) of Child, understand that Northwest Assembly of God, and its affiliated entities, partnering organizations, and / or any of their officers, directors, employees, volunteers, and agents, shall not be responsible for medical expenses incurred on the basis of this authorization, and we hereby agree to hold harmless, defend and indemnify “Northwest AG”, its parents, subsidiaries and affiliates, officers, directors, employees, volunteers, and agents from all obligations, damages, losses, attorney’s fees, defense costs, demands, investigations, actions, liabilities, claims, cross actions, third-party actions, causes of action, of any kind or nature whatsoever, pertaining to the provision of medical services for our Child. It is our express intention to defend, indemnify and hold harmless “Northwest AG” from all claims arising out of, or resulting from, or in any manner relating to the treatment, medical or otherwise, of our Child. I / We agree to notify “Northwest AG” in the event of any health changes, which would restrict the Child’s participation in this trip / event. We also understand that any “Northwest AG” representative reserves the right to restrict the Child from any activity for any reason.
By selecting “I Agree” and / or “signature” box(es) above, I acknowledge that these actions constitute my electronic signature and that my electronic signature has the same force and effect as my manual signature and represents my agreement to agree and abide by the statements described above in their entirety.
Conduct & Emergency Contact Authorization *
I / We understand and agree that if, during the Child’s participation in the activities of the trip / event, Northwest AG learns that he / she is experiencing serious health problems, has suffered an injury, or is otherwise in a situation that raises significant health and safety concerns, then Northwest AG may contact the person whose name is provided as “emergency contact.” I / We understand that while the above-named Child participates on a trip / event, he or she is responsible to comply with all orders and directives of the leader and / or Northwest AG staff and volunteers in charge.
By selecting “I Agree” and / or “signature” box(es) above, I acknowledge that these actions constitute my electronic signature and that my electronic signature has the same force and effect as my manual signature and represents my agreement to agree and abide by the statements described above in their entirety.
GENERAL RELEASE AND ASSUMPTION OF RISK
GENERAL RELEASE AND ASSUMPTION OF RISK *
Knowing the risks, we agree, on behalf of ourselves and our child, family, heirs, and personal representatives, to assume all the risks and responsibilities surrounding our child’s participation in the activities of the Northwest AG sponsored trip / event, both known and unknown, to the maximum extent allowed by law, we release, hold harmless, and agree to indemnify Northwest Assembly of God, and its affiliated entities, partnering organizations, and their officers, directors, employees, volunteers, and agents, from and against any present or future claims, losses, liabilities, costs and expenses for injury to person or property, or for any other damage, which our child may suffer, or for which our child may be liable to any other person, related to our child’s participation in said activities (including periods in transit to or from destinations), resulting from any cause, including but not limited to negligence on our child’s part or on the part of any of the related parties; provided that this release of liability shall not apply to gross negligence or willful or wanton misconduct.
By selecting “I Agree” and / or “signature” box(es) above, I acknowledge that these actions constitute my electronic signature and that my electronic signature has the same force and effect as my manual signature and represents my agreement to agree and abide by the statements described above in their entirety.
PHOTOGRAPH AND VIDEO RELEASE FORM
PHOTOGRAPH AND VIDEO RELEASE FORM *
I / We hereby grant Northwest AG, its affiliates, partners, and agents permission to the rights of the Child’s image, likeness, and sound of their voice as recorded on audio or video tape without payment or any other consideration. I / We understand that the Child’s image may be edited, copied, exhibited, published, or distributed and waive the right to royalties or other compensation arising or related to the use of the Child’s image or recording. I / We agree that Northwest AG may use such images of the Child with or without the Child’s name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. I / We acknowledge that I / We have completely read and full understand the above release and agree to be bound thereby. I / We hereby release, defend, hold harmless and indemnify Northwest AG from any and all claims for utilizing this material.
Participant Name *
Participant Name
By selecting “I Accept” and / or “signature” box(es) above, I acknowledge that these actions constitute my electronic signature and that my electronic signature has the same force and effect as my manual signature and represents my agreement to agree and abide by the statements described above in their entirety.
CODE OF CONDUCT
CODE OF CONDUCT *
As a guest of Northwest AG, I realize I serve as an example to those in the United States and abroad ( if applicable). I understand that I represent not only myself, but also Northwest AG, the United States as a whole, and Northwest AG’s partnering organizations. In respect to Northwest AG and its partners, U understand that I may be asked to be sensitive to local culture issues, to not offend these partners. This would include refraining from drugs, alcohol, tobacco, sexual relations outside of marriage, theft, violence, etc. I further understand that I am not to begin or pursue a romantic relationship with any foreign nations or local workers, team members, or anyone else during the trip / event. I have read, understand, and agree to abide by this policy, and I affirm that I do not have any criminal convictions related to sexual misconduct with an adult or minor, nor do I know of any reason I should not be allowed to work with adults or minors as a volunteer.
Participant Name *
Participant Name
By selecting “I Accept” and / or “signature” box(es) above, I acknowledge that these actions constitute my electronic signature and that my electronic signature has the same force and effect as my manual signature and represents my agreement to agree and abide by the statements described above in their entirety.
PAYMENT INFORMATION
Payment Agreement *
By selecting "I agree" in the following box, I recognize and accept the responsibilities of payment for the aforementioned activity / event. I agree to pay the full price that I am subject to. This price is based not on the date of my registration, but rather the date of my full payment.
FINAL SIGNATURE
I / We certify that I / We am / are legally competent and capable of executing this Agreement on my / our own behalf, that I / we have read the foregoing and have made a conscious decision to sign it of my / our own free will.
Date of Signing *
Date of Signing
By selecting “I Accept” and / or “signature” box(es) above, I acknowledge that these actions constitute my electronic signature and that my electronic signature has the same force and effect as my manual signature and represents my agreement to agree and abide by the statements described above in their entirety.

Payment

To pay online simply click "PAY NOW" and write "Winter Retreat 2019" & the name of the student you are paying for in the notes section.

Earlier Event: February 3
Monthly Focus: Sex
Later Event: February 17
NO YOUTH