agreement form

							                 MERGE
                 *agreement form                       [REQUIRED FOR ADMISSION FOR ALL STUDENTS & ADULTS ]
                                                                                                          GRAND RAPIDS
                                                                                                          JUNE 27-JULY 2, 2010




u   individual info
    NAME                                                          EMAIL

                                      CHURCH                                                 CHURCH
    CELL #                            NAME                                                   CITY

    GRADE                                 MALE        STUDENT     GROUP
    COMPLETED                             FEMALE      ADULT       LEADER



u   medical info
    ALLERGIES, SPECIAL DIETARY NEEDS,                                         CURRENT
    AND HEALTH CONCERNS                                                       MEDICATIONS


    IS PARTICIPANT IS COVERED       YES       INSURANCE
    BY MEDICAL INSURANCE?           NO        CARRIER


    HEALTH POLICY OR                                                          NAME OF
    CARD NUMBER                                                               POLICY HOLDER




u   emergency info
    This form grants permission for the treatment of minors when a parent / guardian cannot be contacted, though in the
    unlikely event of accident or illness, every reasonable attempt will be made to reach the parent / guardian listed below.
    EMERGENCY                                                      RELATIONSHIP
    CONTACT                                                        TO PARTICIPANT


    CONTACT                                                        ADDITIONAL
    PHONE #                                                        PHONE #



u   permission / release
    Parental consent is required for all minors. Adult participants need only sign and date below.

    I, the undersigned (parent or guardian), grant permission for my child to attend and participate in Merge. I consent to
    emergency medical treatment in the unlikely event of accident or illness during my child’s involvement at Merge. I hereby
    release the Merge event staff and event organizers (Echo, Imago, and their associates, and Cornerstone University and its
    employees) from any and all liability that may result from the participant’s involvement in Merge. I, and/or my insurance
    company, assume full responsibility for the payment of any medical bills.

    We the parent/guardian and the participant, also give Echo, Imago, and Cornerstone University the right to use the
    participant’s video or photographic image without charge for any purpose as they deem appropriate, including, but not
    limited to, promotional materials, fundraising presentations or proposals, newspaper or magazine publication or posting on
    a website for promotional purposes.

    I, the undersigned participant, agree to follow all of the guidelines outlined by the Merge event I am attending.



    PARTICIPANT’S SIGNATURE                         PARENT OR GUARDIAN’S SIGNATURE                       DATE

    GROUP LEADERS: Make two copies of each registrant’s agreement form – one for you and one to turn in at event check-in.

                            SEND THIS FORM THIS FORM TO: 1601 562, St. Charles, IL 60174 IL 60174 FAX: 630-762-9901 merge@sonlife.com
                                       SEND TO: 1601 E. Box St., Sugar Unit G, St. 60554 // ONLINE www.mergeexperience.com
    FAX 224-766-7428 // PHONE 224-325-4040 // MAIL P.O.MainE. Main Street Grove, ILCharles, FAX: 630-762-9901 merge@sonlife.com