iServe 2010 Registration Form

iServe
Philadelphia
’10
Name: ____________________________________

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2.26-28.10
Please circle if you are a: guy / girl

Address: __________________________________
Being God’s hands to a city God loves.
Phone number: _____________________________

E-mail address: _____________________________

If you Grade: ______ School: _______________________

register
before the Feb. 7th Church name: ______________________________
deadline, you will be
entered in the Any medicine you must take during the weekend:
drawing to win
a prize! __________________________________________

An iServe T-Shirt is included in this year’s price!

Please select the appropriate size. Then
give your Youth Pastor this form and your
$30 registration cost before 2/7/09!

S ___ M ___ L ___ XL ___ XXL ___

(T-Shirts are adult sizes)

Flip over and have your parent complete the iServe Permission Form
 iServe 2010 Permission Form
I (we) ____________________________ knowingly allow our student
iServe ____________________________, to attend the North Atlantic Youth
Philadelphia Conference in Philadelphia, PA on Friday, February 26th-Sunday
’10
February 28th. I understand that the group will be spending time at

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different Grace Brethren Church locations, including Urban Hope
Training Center. A majority of our time on Saturday will be used to
2.26-28.10
serve the people and the churches of Philadelphia, including using
service projects. I also understand that the leadership of the N.A.Y.F.
and the youth pastors and youth sponsors of these churches and the
Being God’s hands to a city God loves.
employees of the host churches and Urban hope Training Center will do
everything in their power to assure the safety and the well-being of my
I understand that the N.A.Y.F. does student during the event. In the event of a minor injury, I give per-
not carry medical insurance. Here is mission for the leadership to give basic medical treatment. Initial: ____
my student’s insurance information. In the event of a major injury, I give permission for professional medical
treatment, which may include an ambulance ride to the nearest medical
______________________________ facility. Initial: ____
______________________________
(Insurance Co. and policy #)
As my student’s legal guardian, I understand the inherent risks of all
If HMO, include primary care info, if necessary: activities, including this one. The Participant (or parent/guardian)
accepts personal financial responsibility for any injury or other loss
Doctor: _______________________ sustained during the Activity or during transportation to and from the
Phone # _______________________
activity, as well as for any medical treatment rendered to the Participant
that is authorized by the Sponsor, The North Atlantic Youth Fellowship.

Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the
Activity Sponsor for any injury arising directly or indirectly out of the described Activity or transportation to
and from the Activity, whether such injury arises out of the negligence of the Activity Sponsor, the Participant,
or otherwise.

If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to
resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or
parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a
three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.

If my student continually disregards our guidelines, it will be my responsibility, at my expense, to pick my

student up at the event.

_______________________________ _________ _______________________________ _________

(Signature of Participant) (Date) (Signature of legal guardian) (Date)

Name of emergency contact: ___________________________________________________________________________________

Telephone (Day): _____________________________________ Telephone (evening): _____________________________________

List allergies or medical conditions: ______________________________________________________________________________

Flip over and have your student complete the iServe Registration Form