Discount Code

Parent Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Gender *

Birthdate *//

Which campus do you attend? *

Child(s) Information

How many children are you registering? *

Child # 1 Name *

First

Last

Child # 1 Date of Birth *//

Child # 1 Grade *

Child # 1 Medical Notes *

Child # 1 Emergency Contact *

Roommate Request

Do you have a roommate request?

Medical Information

Known Food Allergies/Dietary Restrictions *

Known medical conditions: *

Medications you are currently taking: *

Do you have medical insurance? *

Emergency Contact Name (First person to call in case of an emergency): *

Emergency Contact Phone Number (First person to call in case of an emergency): *

Medical Waiver

I hereby give permission for me and my child/children to attend and participate in activities sponsored by ALLASO RANCH and/or Fellowship Church. •I hereby authorize ALLASO RANCH to transport me and my child/children to or from church and/or any other church related and sponsored activities and events. •I authorize ALLASO RANCH to include me and my child/children in routinely supervised water activities. •I hereby authorize ALLASO RANCH to take me or my child to the closest medical facility for medical treatment in the event of an emergency. The undersigned adult shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to myself or my child/children pursuant to this authorization. Should it be necessary for me or my child/children to return home due to medical reasons or otherwise, the undersigned shall assume and be responsible for the payment of all transportation costs. •I hereby authorize ALLASO RANCH to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care to be rendered to me or my child/children under the general or special supervision and on the advice of any physician or dentist representing to be licensed on the medical staff of a hospital or medical care facility, whether such diagnosis or treatment is rendered at the office of said physician or at the said facility or hospital for me or my child/children. •I hereby do authorize ALLASO RANCH to dispense to me or my child/children any over-the-counter medications (according to proper dosage instructions) when reasonably deemed necessary. •I hereby release, forever discharge and agree to defend and hold harmless ALLASO RANCH from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the undersigned adult that occur while said adult or child is participating in any trip or activity with ALLASO RANCH. •I hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein. •Further authorization and permission is hereby given to ALLASO RANCH to furnish any necessary transportation, food, and lodging for me and my child/children. The undersigned further hereby agrees to hold harmless and indemnify ALLASO RANCH from and against any claim against or loss incurred by ALLASO RANCH as the result of the negligent, willful or intentional acts of myself or my child/children, including any expense incurred attendant thereto. The medical consent and liability waiver provisions hereof shall remain in full force and in effect until written notice of revocation or withdrawal is received by ALLASO RANCH at its office at 2302 Private Road 7850, Hawkins, Texas, Wood County, Texas. •I acknowledge and agree that it is my (our) responsibility to notify Allaso Ranch of any changes in medical condition, guardianship, address or telephone, in writing to the address listed at the beginning of this form. *

Appearance Waiver

The undersigned grants Fellowship Church (“Producer”) and its designees and assignees the right to use my name, likeness, image, voice, appearance, whether recorded on or transferred to videotape, film, slides, photographs, digital media, digital recording, audio tapes, or other media, now known or later developed (individually and collectively the “Product”). This grant includes without limitation the right to edit, mix, or duplicate and to use or re-use the Product in whole or in part as Producer may elect. Producer or its designee shall have complete ownership of the Product in which I appear, including copyright interests, and I acknowledge that I have no interest or ownership in the Product or the Products’ copyright. I also grant Producer and its designees the right to broadcast, exhibit, market, sell, and otherwise distribute the Product, either in whole or in part(s), and either alone or with other products for commercial or noncommercial television or theater, closed-circuit exhibition, home video distribution or any other purpose that Producer or its designees in their sole discretion may determine. This grant includes the right to use this Product for promoting or publicizing any of the uses. I confirm that I have the right to enter into this Agreement, that I am not restricted by any commitments to their parties, and that Producer has no financial commitment or obligations to me as a result of this Agreement. I hereby give all releases and clearances, copyright and otherwise, necessary for the use of my name, likeness, image, voice, appearance and performance embodied in the Product. I expressly release and indemnify Producer and its officers, employees, agents and designees from any and all claims whether known or unknown arising out of or in any way connected with the above granted uses and representations. The rights granted to Producer herein are perpetual and worldwide. I have read the foregoing and understand its terms and stipulations and agree to all of them. As a Christian and a member of Fellowship Church, I recognize that Christians are called by scripture to a different standard of resolving their differences (Matthew 18; 1 Corinthians 6). In the event a dispute arises out of, or relates to this Release, I agree to comply with the Alternative Dispute Resolution Policy of Fellowship Church, before commencing arbitration, litigation, or other dispute resolution procedure. *

Total

$ 0.00

Credit Card *

Card Number

Security Code

Name on Card

Expiration/