EVENT REGISTRATION

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Event

Please select the event you are registering for from the dropdown list.

General Info

Name

First

Last

Phone

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

I certify that I am at least 18 years old

Birthdate

Gender

Dietary Restrictions & Medical Info

Do you have any food or dietary restrictions?

Emergency Contact

First

Last

Emergency Contact Phone

Medications

Physician Name

First

Last

Physician Phone

Physician Address

Address Line 1

Address Line 2

City

State

Zip Code

I have had a physical in the last 24 months

Medical Insurance Company

Medical Insurance Policy Number

Medical Insurance Phone

Agreement

Indemnity & Contract Agreement

I will not hold or attempt to hold Reclaim Ministries, Inc. liable for any loss, damage or injury to person or property caused by any act or neglect of other persons during the event or on or about the Property, or caused in any manner other than the willful or negligent act of Reclaim Ministries, Inc, its agents and employees, and will indemnify and hold harmless from any liability for damages or claims against Reclaim Ministries, Inc. arising out of or in any way related to any such loss, damage or injury.

I release Reclaim Ministries, Inc., including its board members, volunteer staff, employees and agents, from my physical injury, including death, or illness during the event or while at the Property. I will assume the risk associated therewith, whether known or unknown to me at this time. This release is also intended to include all claims of my family, estate, heirs, personal representatives or assigns.

Authorization for Treatment

I hereby give permission to the medical personnel selected by the event director to secure and administer treatment and to maintain and/or release any medical records necessary for insurance purposes as outlined under the HIPAA regulation, and to provide or arrange necessary related transportation for the above named person. I verify that I am in good health and am capable of participating in strenuous activities, and when necessary, will tailor my activities to those within the bounds of my physical health. In Colorado, participants will engage in rigorous activities at 9,000 to 14,000 feet. I agree and confirm that my health insurance and/or I am personally responsible for the expense of any medical treatment that is provided to me while attending a Reclaim Ministries, Inc. event.

I Agree

I agree to the Indemnity & Contract Agreement

Payment Info

Coupon Code

Please enter coupon code and click "Apply"

Credit Card