2018 Deepening Camp;July 23rd- July 27th;Arlington, TX

Deadline to sign up is March 28th. Spots will be held until capacity is full.

Name of Participant: ______

Address: ______

City: ______State: ______Zip: ______

Telephone: ______Date of Birth: ______

Name of Emergency Contact: ______

Relationship:______

Address:______

City: ______State: ______Zip:______

Telephone:______

Evening Day Cell

Medications you are currently taking:______

______

Medications, food, or other allergies you have: ______

______

Is activity director authorized to approve medical treatment? __ Yes __ No

Is participant covered by personal/family medical insurance? __Yes __ No

If yes, name of insurer: ______

Policy or group number: ______

PARTICIPATION AGREEMENT

By signing below, the participant acknowledges that FirstAssemblyofGodNorthLittleRock, Inc. gives the participant the opportunity to be involved in the above activity, and in return the participant accepts responsibility for any physical injury, emotional damage, and accepts personal financial responsibility for any bodily/personal injury along with any emotional damage sustained during the activity. By signing below, the participant releases FirstAssemblyofGodNorthLittleRock, Inc. from liability for its negligence. Further, the participant promises to hold harmless FirstAssemblyofGodNorthLittleRock, Inc., 4501 Burrow Drive, North Little Rock, Arkansas, and its representatives to the fullest extent permitted by law for any injury related to the activity.If a dispute over this agreement or any claim for damages arises, the participant agrees to resolve the matter through a mutually acceptable arbitration process.

Signature (Parent’s signature if under 18):______

Date:______

Gender: Male _____ Female _____

Class of: ______

Shirt Size: ______

Participating in the meal plan (pre-paid $100): Yes _____ No _____

I would like to room with (list two names from your grade):

1. ______

2. ______

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FOR OFFICE USE ONLY:

Total Amount Due: $378 ($478 if participating in the meal plan)

Deposit ($126): ______

2nd Installment: ______

Final Payment: ______

Meal Plan: ______

Deepening Activity Options

This year at The Deepening, you get to choose one of your activities. This will not be a class activity. It will be an activity for anyone who wants to go. The three options are:

Hurricane HarborMain Event The Parks Mall

Main Event includes bowling, unlimited pool, unlimited laser tag, a $10 fun card for games, and pizza for lunch.

Please circle one activity you would like to attend, and write your name & class at the bottom. The DEADLINE to turn this form in is April 25th. You can detach this form to give you more time to make your choice. This form is separate from your Deepening registration form.If we do not receive your activity form by April 25th, we will mark you as going to the mall. Choices can’t be changed after April 25th.

PRINT NAME:______Class:______