Fall Retreat — Chi Alpha

1) REGISTRATION

Name

First Name

Last Name

Cell Number

(###)

###

####

Email Address

Sex

Small Group

Carpool

Carpool: Departure Time

Emergency Contact

First Name

Last Name

Emergency Contact Cell Number

(###)

###

####

Dietary Restrictions and Medical Conditions (if any)

Liability Waiver

Please read the liability waiver found below

I agree to the Travel Liability Release statement

2) PaymenT

Food and lodging for the weekend costs $100. If you are a freshman or this is your first fall retreat, generous alumni have given to discount your price to $75. Both scholarships and payment schedules are available, we never want money to be a barrier for you to come! If you need assistance, just email Julie at info@chialphaumn.org

CHI ALPHA TRAVEL LIABILITY RELEASE STATEMENT

IN CONSIDERATION of my acceptance as a participant for the above activity in cooperation with the Assemblies of God, and other considerations the sufficiency of which is acknowledged, represent and agree that:

1. Status. I attest and certify that I am physically fit and have no medical conditions that would prevent me from participating in the above-referenced activity.

2. Risks of activity. I am aware of the hazards and risks to my person and property associated with serving in the above activity, such hazards and risks including but not being limited to injury; increased stress; accident; disease; inadequate medical services and supplies; death; criminal acts (including terrorism); natural disasters; weather conditions; government action; risks of traveling to or from destinations. I recognize that I may be subjected to potential risks, illnesses, injuries, and even death. I have made my own investigation of these risks, understand these risks, and assume them knowingly and willingly. I understand and agree that if, during my participation in the above-described activities, the leader learns that I am experiencing serious health problems, have suffered an injury, or am otherwise in a situation that raises significant health and safety concerns, then the leader may contact the person whose name I have provided as my "emergency contact." I understand that the leader ordinarily will not initiate such contact without first having a discussion with me.

3. GENERAL RELEASE AND ASSUMPTION OF RISK: KNOWING THE RISKS DESCRIBED ABOVE, I AGREE, ON BEHALF OF MY FAMILY, HEIRS, AND PERSONAL REPRESENTATIVES, TO ASSUME ALL THE RISKS AND RESPONSIBILITIES SURROUNDING MY PARTICIPATION IN THE ABOVE-DESCRIBED ACTIVITIES, BOTH KNOWN AND UNKNOWN. TO THE MAXIMUM EXTENT ALLOWED BY LAW, I RELEASE, HOLD HARMLESS, AND AGREE TO INDEMNIFY THE GENERAL COUNCIL OF THE ASSEMBLIES OF GOD, AND IT’S AFFILIATED MINISTRIES, AND ANY ASSEMBLIES OF GOD CHURCH AND/OR DISTRICT COUNCIL, AND ANY ASSEMBLIES OF GOD SCHOOL, COLLEGE OR UNIVERSITY, 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 I MAY SUFFER, OR FOR WHICH I MAY BE LIABLE TO ANY OTHER PERSON, RELATED TO MY PARTICIPATING IN SAID ACTIVITIES (INCLUDING PERIODS IN TRANSIT TO OR FROM MY DESTINATIONS), RESULTING FROM ANY CAUSE, INCLUDING BUT NOT LIMITED TO NEGLIGENCE ON MY PART OR ON THE PART OF ANY OF THE RELEASED PARTIES; PROVIDED THAT THIS RELEASE OF LIABILITY SHALL NOT APPLY TO GROSS NEGLIGENCE OR WILLFUL OR WANTON MISCONDUCT.

4. I expressly waive any defense to the enforcement of any provision of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me enforceable against me in accordance with its terms.

5. Invalidation of any one or more of the provisions of this Agreement shall in no way affect any of the other provisions hereof, which shall remain in full force and effect.

6. I expressly agree that this assumption of risk, release, and indemnity agreement is intended to be as broad and inclusive as permitted by law. I further state that I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND ITS CONTENTS, AND I VOLUNTARILY SIGN THIS AGREEMENT AS MY OWN FREE ACT.

7. I grant Chi Alpha, its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Chi Alpha, its assigns and transferees to copyright, use and publish the same in print and/ or electronically. I agree that Chi Alpha may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.

I certify that I am age 18 or older. I understand and agree that no oral written representations can or will alter the contents of this document. This Agreement shall be governed and construed in accordance with the laws of the State of Minnesota, excluding its choice of law rules, and all claims relating to or arising out of this Agreement, including claims for injuries or wrongful death in any way related to the above-described activities, shall likewise be governed by the laws of the State of Minnesota, excluding its choice of law rules.