1. technology and computing
2. consumer electronics
3. telephones
4. mobile phones

 Logos Youth Retreat 2014 Nov. 7th – 9th
Camp Akita 29746 Logan­Hornsmill Rd. Logan, Ohio 43138
Dropoff Time: Friday 5:30pm – 7:30pm Pickup/Depart Time: Sunday 1:30pm (Note – transportation is the responsibility of each attendee, see registration form)
Please Register Early ­ Cost: $75 per person. Make checks payable to Logos Bible Church Youth Group All Attendees must register! Registration Forms are available from your local youth leaders and may be requested via email or downloaded from: www.logosbiblechurch.org/ministries (go to neXt Youth Group) Please contact Doug Smith for information: [email protected] 614­940­4193
Logos Bible Church - Youth Retreat
Camp Akita
29746 Logan-Hornsmill Rd.
Logan, Ohio 43138
Camp Phone: 740-385-3827
Logos Retreat Director: 614-940-4193
neXt Youth Group
Registration Type:
Registrar Use:
Name:
M F
Meds:
Allergies:
Age:
Note:
Form:
Paid:
Check-In:
Check-Out:
Logos Bible Church Youth Retreat
Registration Form
☐ Youth
☐ Counselor (Jr.|Sr.|Any)
☐ Staff:
Participant’s Name: ___________
__________
_______________
Date of Birth: _____________ Email: __________________________________ (for future retreat announcements)
(service area)
Gender: Male Female Age: _________
TRANSPORTATION (for youth): Transportation is NOT provided to or from the Retreat. I
t is the responsibility of each parent to provide for or arrange transportation for their children to/from the retreat. Upon completion of the retreat, my child may ride with the following individuals from the retreat: ☐ Legal Guardian (must be the primary contact below) ☐ Other: ___________________________ (must be named in order to release your child from the retreat to someone other than the Legal Guardian GENERAL: A ddress: Street ______
_
_____________________ C ity ______________ State ____ Zip _______ Phone (___)_______________
Primary C ontact (Parent/Guardian/Spouse/Other): __________________________________________Relationship_____
_
______ Primary C ontact Phone #’
s: Home: ____________________________Work : ____________________________C ell /Other: _______
________________
__ PHYSICIAN & INSURANCE INFORMATION Family Physician'
s Name ________________________
__________________________________ Phone (___)_________
_
_____
Medical/Hospital Plan: _
_____________
_______________________ Policyholders First & Last Name _____________________ Health I
nsurance C ompany/C arrier ____________________________________________ Policy or Group # __________
_______
MEDICAL CONDITIONS / ALLERGIES / MEDICATIONS: List A ny Medical C onditions:________________________________________________ (for A sthma, does participant carry an inhaler?___) List A ny A llergies: ___
_____________________________________________________ (does participant use an epi­pen?___) Prescribed Medications (at retreat) (name)___________________________________ (use)_________________________
______
(name)_
__________________________________ (use)_________________________
______
I
n case of pain and primary contact can not be reached, participant may be given: ☐ A cetaminophen (Tylenol) ☐ I
uprofen (A dvil) ACKNOWLEDGEMENT OF RISK AND RELEASE: For myself / my child, I
ex pressly, k nowingly and voluntarily assume all risk s involved in my/my child’
s participation in the above­identified program. I
ex pressly give consent for myself/my child to travel with Logos B ible C hurch (LB C ) in a vehicle operated by an adult to/from the LB C retreat location and an agreed upon pick ­up/drop­off location for myself / my child. Therefore, I
do hereby release LB C and its members, trustees, officers, employees, independent contractors and agents from any and all liability, damages, costs and ex penses arising out of or relating to bodily or psychological inj ury, loss of life or personal property that may occur as a result of participating in and traveling to/from this program. Authorization for treatment: I
hereby give permission to the medical personnel selected by LB C to arrange necessary related transportation for this participant and assist with prescription and over­the­counter medication if needed (as indicated above in this form). I
n the event I
cannot be reached in an emergency, I
hereby give permission to the physician selected by LB C or the host facility to secure and administer treatment, including hospitaliz
ation, for the person named above. Photography release: I
grant to LB C , the right to tak e photographs of me/my child in connection with the above­identified program. I
authoriz
e LB C , its assigns and transferees to copyright, use and publish the same in print and/or electronically. I
agree that LB C may use such photographs of me/my child with or without my name and for any lawful purpose, including for ex ample such purposes as publicity, illustration, advertising, and Web content. Counselors and Staff only: I
hereby consent and authoriz
e LB C and its authoriz
ed agents to conduct a back ground check on me which may include a criminal history check and sex and violent offender registry check . I
hereby agree, upon written or verbal request from LB C staff, to provide the required personal information to LB C for this purpose. I
understand and agree that LB C reserves the right to deny involvement of any individual in the above­identified program. I
have read and understand and accept the terms and conditions stated herein and ack nowledge that this agreement shall be effective and binding upon the parties during the entire period of participation in the above­identified program. ________________________________________________________
REQUIRED: Signature of participant
Date
_____________________________________________________________
REQUIRED: Signature of Parent (If participant is under 18)
Please send this application and payment of $75 to:
Doug Smith / #118
Logos Bible Church
623 Hill Rd. North
Pickerington, OH 43147
(614) 940-4193 Date Logos Attendees:
Doug Smith
Mail Slot #118