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KB2018 Registration
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Last Name *
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Email *
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Adult T-Shirt Size
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T-Shirt Color ($15)
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Church Name and Denomination
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Senior Pastor's Name
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Select Registration Type *
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with Room & Board $250
with Room & Board + T-shirt $265
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Do you have any special needs that we need to be aware of? (allergies, handicap, etc.)
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Consent *
I Agree
I, an undersigned adult (age 18 and over) or parent or guardian of the minor/participant listed above, do hereby authorize adult workers with Kingdom Breakout Ministries to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said.
I do hereby expressly consent that I or my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for rendering such services.
I as adult or parent or guardian voluntarily releases, discharges, waives and relinquishes all claims that they may have against the Kingdom Breakout Ministries, its officers, staff and volunteers, for any and all claims, actions, or causes of action for personal injury, property damage or death that may be sustained in engaging and participating in various activities during the retreat.
I understand that if the retreat participant does not comply with school and staff rules, he/she may be forced to leave conference grounds without refund.
I Agree
I, an undersigned adult (age 18 and over) or parent or guardian of the minor/participant listed above, do hereby authorize adult workers with Kingdom Breakout Ministries to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said.
I do hereby expressly consent that I or my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for rendering such services.
I as adult or parent or guardian voluntarily releases, discharges, waives and relinquishes all claims that they may have against the Kingdom Breakout Ministries, its officers, staff and volunteers, for any and all claims, actions, or causes of action for personal injury, property damage or death that may be sustained in engaging and participating in various activities during the retreat.
I understand that if the retreat participant does not comply with school and staff rules, he/she may be forced to leave conference grounds without refund.
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