New Heights Registration

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New Heights Registration

Type of Registration*
- Youth Registration
- Adult Registration
- Group Registration
Are you attending New Heights with your group?
- Yes, I wouldn't miss it!
- No, I'm just registering the group.
Name*
First Name Middle Last Name
Gender*
Date of birth*
Date Format: MM slash DD slash YYYY
Grad Date*
T-shirt size*
Cell*
Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Group Leader*
First Last
Number of youth in your group:*
If unsure, provide an estimate.
Number of adults in group:*
If unsure, provide an estimate.
Note: Background checks are required for all adults working with youth. If you have a background check already completed, please send that to us.
Note: Background checks are required for all adults working with youth. If you or an adult in your group has a background check already completed, please send that to us.
Name of Group*
Who's coming with you?*
Anything else KMBC should know?
The following information is needed so that KMBC can run a background check. Sensitive information will not be shared with unnecessary parties.
Maiden name and/or other aliases*
Social Security #*
Drivers License #*
I release KMBC to perform a background check on me. I understand that this background check will be used to inform churches and camps of my fitness to serve.*
- I agree.
- I disagree.
I understand the information supplied by me must be truthful and falsification with an intent to mislead may result in my prosecution under KRS 523.100. I have provided the basic information necessary to qualify for record processing.*
- I understand and accept.
- I do not accept.
Parent/Guardian*
First Last
Parent/Guardian Cell*
Parent/Guardian Home/Work Number
Parent/Guardian Email
Is parent/guardian emergency contact?*
- Yes
- No
Emergency Contact Name*
First Last
Emergency Contact Phone*
Medical Conditions/Allergies (please list)
I the undersigned parent/guardian, hereby consent to my child participating in the youth camp, an event sponsored by Kentucky Mountain Bible College, June 24-28, July 22-26, July 29-Aug 2, 2019. I certify that my child is able to participate in the camp activities as listed in the brochure and otherwise. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them. In the event of an emergency, I may be reached at the telephone numbers listed above. If I cannot be contacted, I hereby authorize Kentucky Mountain Bible College, its agents or employees to obtain such medical treatment as may be necessary in their judgment to ensure health, safety and well-being of my child. I understand and hereby agree to assume all risks which may be encountered on said activity, including activities preliminary and subsequent there to. I hereby agree to hold Kentucky Mountain Bible College, their agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child, property even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release, waiver and indemnity agreement is intended to be broad and inclusive as permitted by law of the State of Kentucky and that if any portion thereof is held invalid; it is agreed the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and a mere recital. I will disclose and update any changes that may occur to this release before the date of the event. I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understood.
I, the undersigned parent/legal guardian, have read the above statement and agree.*
- Agree
- Disagree
Signature
Insurance Company*
Insurance Policy #*
Are you coming with a group?*
- Yes
- No
Name of group or group leader:*
Which camp will you (or your group) be attending?*
- Camp 1: June 24-28th, 2019
- Camp 2: July 22-26th, 2019
- Camp 3 (Creation themed): July 29-Aug 2, 2019
- Unsure

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