Sa-rang English Jr.

High 2012 JESUS ULTIMA Winter Retreat Registration Form

Camp Maranatha: 54162 Maranatha Drive, Idyllwild-Pine Cove, CA 92549 (951) 659-2739 Departure from Church: 12-26-12 Wednesday @ 1:00PM - Arrival to Church: 12-29-12 Saturday @ 1:00PM ***Lunch will not be provided on 12-26-12 (Wednesday) ***No applications will be accepted on the date of departure! ***No refunds will be given after registration!

STUDENT NAME

M
Last Name First Name (select gender)

F
Grade

HOME ADDRESS
Street Address City Zip

CONTACT INFORMATION

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Home Phone Number

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PARENT/GUARDIAN INFORMATION

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Student Cellular Phone Number FUEL Group Name

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Parent / Guardian Name Relationship to Student

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Parent / Guardian Phone Number

MEDICAL CONDITIONS

Please list any allergies, mediations, chronic illness, and relevant medical information of the student. If there are no medical conditions, please write None.

PAYMENT INFORMATION

$120.00 - On or before December 2nd

$140.00 After December 17th

* NO APPLICATIONS WILL BE ACCEPTED ON THE DAY OF THE RETREAT!!! * CHECKS MUST BE PAYABLE TO SRCC!

$
Total Enclosed Amount

Cash

Check

#
Check Number

(Method of Payment)

Participation Terms & Conditions

Attend Sarang English jr High School Ministry 2012 Summer Retreat with an open heart, teachable mind, humble attitude, and respect for others. 1. All students must follow the instruction of any and all Youth Ministry leaders and abide by all camp rules & regulations. 2. Students are not allowed to leave All Nations Prayer Mountain facility without permission from Adult Youth Ministry leaders. 3. Students are prohibited from possession or usage of any and all electronic devises such as, but not limited to iPod, any and all electronic music playing devise, cellular phones, electronic games, and playing cards. Any and all electronic devises & gadgets will be confiscated. 4. Students are prohibited from possession or usage of cigarettes, alcoholic beverages, and any and all illegal substances. 5. Students are prohibited from engaging in any physical violence and/or usage of inappropriate language at all times. 6. Male students are strictly off-limits in all female cabin rooms, and female students are strictly off-limits in any and all male cabin rooms.

NO Tolerance Policy
Any student, hereinafter referred to as Participant, who fail to follow above Participation Terms & Conditions line item #4, #5, and #6 will result in immediate dismissal from Camp Maranatha without any exceptions. In case of dismissal, the Participants parent or legal guardian will be required to pickup the Participant to be sent home without a refund.

Full Release and Hold Harmless Agreement

I do hereby fully release, forever discharge and agree to defend indemnify and hold Sarang Community Church, hereinafter referred to as SRCC, harmless from any and all liability, claims or demands for personal injury, sickness, illness or loss, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned Participant that occur while participating in the above described trip or activity. The authorized person signing below acknowledges and agrees that such trip or activity inherently involves some degree of risk so that Participant may incur personal injury or bodily damage and SRCC would not allow involvement by Participant without the foregoing full release and agreement to hold SRCC harmless. Furthermore, I (and for and on behalf of my child participant if under age of 18 years) hereby assume all risk of personal injury, sickness, illness, loss, damage and expense resulting or relating to Participant in activities involved herein. Parent or legal guardian hereby authorizes and gives permission to SRCC to furnish and guidance, discipline, transportation, food and lodging determined necessary for this Participant.

Medical Treatment Authorization Agreement

I am the parent or legal guardian of Participant, and I hereby grant my permission for Participant to participate fully in said trip or activity, and hereby give my permission to the physician or dentist selected by SRCC to hospitalize, to secure proper treatment, and/or order injection, anesthesia, surgery, and/or other medical treatment for Participant as deemed necessary. I further assume the responsibility for and promptly pay all medial bills, if any, and should it be necessary for the Participant to return home due to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all transportation and associated costs and expense. The person signing below represents and acknowledges he or she (a) fully understands and agrees to each of the terms of this document, (b) has had sufficient opportunity to have this document translated (or has chosen not to do so), provided the English language shall control in all respects, and (c) that the authorized signature below covers terms & conditions, a full liability release and medical release.

Student (must be signed)

Parent / Guardian (must be signed)

Student Signature

Parent/Guardian Signature

Print Name

Date

Print Name

Date

Contact info: Joe Oh JDSN (714) 321-4904 / Vivian Yoo JDSN (562) 484-4404 / Jason Kim BJN (949) 275-5531