CIY Move 2024 (7-12 grade)

Wellspring Students will be attending
CIY MOVE
at Lee University in Cleveland, Tennessee
June 30- Jul 6, 2023.

The Rest of Your Life:

Do your feel pressured?
To measure up?
To be the best, the brightest, the funniest, the strongest?
To try harder, work longer, never let up, never give in, never quit?

Do you wonder what you're going to do with the rest of your life?
Does all your striving, all your efforts to keep up, to stand out, to be noticed, to make someone proud only lead to being tired, exhausted, burnt-out, worn-out, fatigued, and weary?

If so, then Jesus has something he wants you to hear,
"Come to me, all you who are weary and burdened, and I will give you rest."

Join us this summer and let Jesus give you the REST of your life - for the rest of your life.

Student Information

Please fill out the student's information below.

Student Name

Student's Gender

Student's Date of Birth

Student's Grade (2024/25) School Year)

Student's Primary Address

Student Phone Number

Student Medical & Insurance Information

Please fill out student's medical and insurance information below.

Insurance Company

Primary Named on Insurance Policy

Group Policy/Member Number

Student's Primary Physician

Physician's Phone Number

Allergies (Please list all allergies and diet restrictions here; ex: Peanuts, Latex, Amoxicillin, etc)

Is there anything else Wellspring or CIY Move Staff should be made aware of? (medications, physical limitations, sports restrictions, medical history, behavior diagnoses)

Primary Parent/Guardian Information

Please fill out the primary parent or guardian's information here.

Name

Phone

This address will receive a confirmation email

Address (if different from student's)

Relationship to student

If "Other" please describe relationship to student here.

Secondary Parent/Guardian/Emergency Contact Information

Please fill out the secondary parent/guardian or other emergency contact information here.

Name

Phone

Address (if different from student and primary parent/guardian)

Relationship to student

If "Other" please describe relationship to student here.

Parent/Guardian Authorization, Consent, and Release

I, ____________________________, parent/guardian of ______________________________, hereby grant my permission for the above-named child to participate in CIY Move on July 2-8, 2023 (the “Event”), sponsored by Wellspring Church (the “Church”).

I understand the Event may include, but is not limited to the following: transportation provided by the Church to and from the Event, meals, and lodging. Recreation and activities during the event may include, but are not limited to the following: Bible teaching, worship, prayer, indoor and outdoor activities including water activities and physical exercise.

I understand it is my obligation to inform the Church of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities while in the care of the Church. Should the need for medical attention arise I understand the Church will attempt to contact me as soon as practicable under the circumstances.

In cases of emergency, I further consent to the examination and treatment of my child by medical personnel as deemed necessary by such personnel. I agree to pay for any and all resulting medical expenses. I agree to waive, forever discharge, covenant not to sue and agree to hold harmless all Event volunteers and the Church, their agents, representatives, employees, sponsors, successors and assigns (“the Released Parties”), from all liability, claims, demands, losses or damages on account of or caused by, whether actual or alleged, in whole or in part, any act or omission of the Released Parties in connection with my child’s participation in the Event.

I acknowledge by signing this document I am waiving my right to maintain a lawsuit against the Released Parties on the basis of any claim from which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions remain in full force and effect. I have fully informed myself as to the contents of this PARENTAL AUTHORIZATION, CONSENT AND RELEASE by reading it before I signed it.

By typing your full name and the current date, you are electronically signing this form and acknowledging that you have read the above Parent/Guardian Authorization, Consent and Release, that all repsonses in this form are true, and that your online consent is equivalent to a binding legal signature.

Full Parent/Guardian Name

Current Date

Payment

Payment goes towards to cost of: transportation to and from CIY Move, activities and lodging at CIY Move (including one night's hotel stay on the way to Move).

Students will be required to pay for an additional 4 meals to and from camp. It is also recommended students bring cash or card for snacks and promo items at the CIY Move store.
For this resason, we recommend students bring between $75-150 cash.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

CIY Move 2024 (7-12 grade)

Description

Please Fix the Following