Kairos Summit-- Youth Registration Form

Kairos Summit- Youth Registration Form

Parents and legal guardians of minor children are asked to complete this form and return it to Kairos. The information requested is designed to assist Kairos in providing for the safety of minors during the short-term trip "Kairos Summit" for the time period of June 28 - July 2.
General Information
Participant's Name*

First NameLast Name
Participant's Email*
example@example.com
Participant's Phone Number*
Please enter a valid phone number.
Age at the time of the trip
Date of Birth*

MonthDayYear
Date
Grade Currently Completing

11th Grade12th Grade
What is your denomination?*
If denomination is not listed, please let us know!
What community are you from?
What is your sweatshirt size? (Sweatshirts are unisex sizes)

SMLXLXXL
Parent 1 Name*

First NameLast Name
Parent 2 Name

First NameLast Name
Parental Contact Email*
example@example.com
Second Parental Email (include if you want both parents to receive communication)
example@example.com
Parental Contact Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1 Description*
e.g. Dad cellphone, Grandma cellphone, etc.
Emergency Contact #1 Number *
Please enter a valid phone number.
Emergency Contact #2 Description
e.g. Dad cellphone, Grandma cellphone, etc.
Emergency Contact #2 Number
Please enter a valid phone number.
Family Doctor *

First NameLast Name
Doctor's Number*
Please enter a valid phone number.
Participant's Insurance Company*
Policy Number*
All Kairos Summit participants must have medical insurance. If a participant does not have medical insurance, medical insurance must be purchased in advance and specific information pertaining to that policy included above. Kairos, their agents, employees, or volunteers will not be responsible for medical expenses incurred during an adventure trip.
Consent and Certification
We, the undersigned, being the parents or legal guardians of the participant named above, do hereby consent to the participation of our child in a short-term adventure trip to the above named location. We are aware of the hazards and risks to our child associated with participating in such a trip, including but not being limited to death or injury by accident, illness, weather conditions, inadequate medical services, criminal activity, and random acts of violence and understand that these trips include transportation by car or van, camping, canoeing, hiking, backpacking, swimming, jumping into the water from objects on shore, fishing, and the many outdoor activities normally associated with camping routines in a wilderness environment.

We certify that our child is physically fit and has no medical conditions that would exclude him or her from participating in this adventure trip.

We understand that while our child participates in the Kairos Summit to the above named location, he or she is responsible to abide by the rules established by Kairos and the instructions of its representatives. Any infraction of the rules, or of any instructions from an authorized Kairos representative (trip leader, chaperone, or sponsor), can result in the dismissal of our child from the trip. In the event our child is dismissed from further participation in this trip due to a refusal to abide by rules or instructions, we, the undersigned, agree to assume the cost of returning the child to his or her home. We also agree, under these circumstances, to forfeit any right to a refund from Kairos of any pre-paid fees or expenses. We understand that such an action would only be taken after notification of the Trip Leader and the undersigned.

We also give permission for pictures to be taken that may be used in, but not limited to, Kairos publications, staff newsletters, and shared participant online folders.
We DO NOT authorize our child to participate in any of the following activities:
Please explain, if applicable
Medical Questionnaire
Is your child presently being treated for any injury or sickness or taking any form of medication for any reason?*

YesNo
Please explain, and if applicable list medications
Does your child have (or has ever had) and of the following medical conditions?*

AsthmaDiabetesHay FeverHeart MurmurKidney DiseaseSeizure DisordersNone
Please Explain
Is your child allergic to any type of medication?*

YesNo
Please list medications and explain if necessary
Does your child have any allergies other than to medications (e.g. food allergies)?*

YesNo
Please explain
Can your child swim?*

YesNo
Does your child have any physical condition or illness which would prevent him/her from participating in normal rigorous activity?*

YesNo
Please Explain
Kairos Summit staff are trained in Christian youth work, wilderness camping/survival skills, and basic first aid. Some emotional or behavioral issues may require special awareness from the staff. Please indicate any areas here so that we can discuss them with you before our trip. Does your child have (or has ever had) any of the following?*

Sleep-WalkingBed-WettingHome-SicknessSelf-Harm and/or suicidal thoughts or actionsViolent BehaviorProblems Dealing with EmotionsEating DisorderAnxiety/Depression/Panic AttacksDisciplinary Problems at Home or at SchoolCare from a Psychiatrist, therapist, counselorNone
If your child has any other issues that weren't listed above, or if you would like to further explain anything that you selected above, please explain here.
Medical Treatment Authorization and Insurance Election
We understand that we will be notified in the case of a medical emergency involving our child. 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 our child is injured or becomes ill. We authorize any one or more of the following persons to make emergency medical care decisions on behalf of our child, if required by law or a health care provider: Stephen Giles or Molly Kilpatrick. We understand that Kairos, or any of their agents, employees, or volunteers, will not be responsible for medical expenses incurred on the basis of this authorization.

We are aware of the hazards and risks to our child associated with an adventure trip. We understand that the Sword of the Spirit (the parent corporation of Kairos) carries general liability insurance only. We understand that this general liability insurance does not cover medical evacuation and medical treatment for children participating in this activity. It is the parents’ responsibility to provide insurance to cover medical evacuation and medical treatment of their children who participate in Kairos activities.
Please check the appropriate box:*

We do not desire any additional insurance coverage for our child other than that described above.We do desire additional insurance coverage, and we assume full responsibility for obtaining such coverage from a private insurance carrier at our own expense.Other
Signature and Payment Information
Signature of Parent/Guardian #1*

Clear
Date*

MonthDayYear
Date
Signature of Parent/Guardian #2

Clear
Date

MonthDayYear
Date
If signed by only one parent, please specify why:
Cost
How are you paying?*

Pay by credit card (this will include a 2.5% processing fee)Pay by check
Make the check out to: The Sword of the Spirit

In the memo line write: Kairos Summit and the names of the people you're paying for

Mail to:
Attn: Kairos Summit
Kairos
1417 1/2 E. Michigan Ave.
Lansing, MI 48912

Please note: The full transportation cost to and from the trip is not totally included in this price. Transportation from Michigan to the trip sites should be already covered, but not extra expenses along the way (fast food, etc.). Kairos can assist your son in getting to and from the trip start location, but you may be asked to give extra for gas money or to help cover a car pool, depending on the situation.

Credit Card Payment

Kairos Summit

$425.00

Total

$0.00

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Kairos Summit- Youth Registration Form

General Information

Consent and Certification

Medical Questionnaire

Medical Treatment Authorization and Insurance Election

Signature and Payment Information