Western States Youth Gathering
June 27 – July 1, 2014
California Lutheran University, Thousand Oaks, CA
Group Registration
Part 1
Congregation Name:
Congregation Phone:
Congregation Address:
City:
State:
Zip:
Group Leader Name:
Group Leader Phone:
Group Leader Email:
X $100=
Deposit
Total # Registered:
Group Registration
Number
Youth/Adult
First Name
x$399 =
or Payment
in Full
Part 2
Last Name
Sex
1
2
3
4
5
6
7
8
9
10
(to pay by check, include the registration form with payment and send to California Lutheran
University, Church Relations Office, 60 W. Olsen Road, #2125, Thousand Oaks, CA 91360)
Age
Forms – Liability Release
Part 1: Release of Liability (part 1, every participant must sign)
By submitting this form I allow my name as part of an information database for WSYG-related
entities, and that photos/videos produced by 2014 Western States Youth Gathering become
the property of the WSYG and can be used for WSYG-related purposes and publicity.
I hereby confirm that I have voluntarily chosen to participate in the 2014 Western States Youth
Gathering planned and arranged by volunteers of California Lutheran University for June 27 –
July 1 in Thousand Oaks, California. I am aware that the 2014 Western States Youth Gathering
presents risk of personal injury and property loss or damage to participants. I expressly and
voluntarily assume all such risks that may result from my participation in the 2014 Western
States Youth Gathering.
I hereby release California Lutheran University (CLU), its agents, affiliates, and successors from
all liability for injury, death, or other loss of damage resulting from my participation in the 2014
Western States Youth Gathering. I have read this agreement and release fully understand its
contents. I sign it of my won free will.
Participant Signature: _______________________________________ Date: ____________
Part 2: Agreement and Release of Liability (part 2, parents & guardians must sign)
As legal guardian of the minor who signed Part 1 of this Agreement and Release of Liability, I
hereby assent to the foregoing agreement on my own behalf and on behalf of the minor and
her/his heirs and assigns. I further accept unto myself all responsibility and all liability for any
injury, death, or other loss of damage that occurs to me and/or to the minor as a result of the
minor’s participation in the 2014 Western States Youth Gathering.
I will indemnify and hold harmless the CLU, its agents, affiliates, and successors from all claims,
judgments, and cost, including attorney’s fees, incurred in connection with any action that may
be brought as a result of the minor’s participation in the 2014 Western States youth Gathering,
June 27 – July 1 in Thousand Oaks, California. I have carefully read this agreement and release
and I fully understand its contents. I sign it of my own free will.
Parent/Guardian Signature: ______________________________________Date:___________
For Office Use Only: Date Received: ______________________ Congregational ID #: ________________
Forms – Medical Release
All attendees, youth and adult, must bring this with them to the Gathering. Include information
about your primary insurance carrier and photocopy your insurance card. You will be asked to
produce this form in certain Gathering activities, such as Servant Events. We recommend that
the Primary Leader be responsible for holding forms of everyone in the congregation.
I, the undersigned, hereby authorize my councilor or a staff representative of the Western
States Youth Gathering to consent to and authorize the administration and performance of all
treatments that may be considered advisable or necessary in the judgment of attending
physicians, in the event I should be admitted to any hospital, or be in need of any medical
treatment. This authorization shall continue for such time as I am participating in the abovenamed youth gathering during travel to and from said program.
Please photocopy and complete two copies of this form for each adult and youth that will
attend the Gathering. Keep one with you at all times and give the other copy to the registration
team at the time of check-in.
Please print the following information:
Participant’s Name:
____________________________________________________________________
Parent/Guardian Name:
_______________________________________________________________
Address:
______________________________________________________________________________
City: __________________________________ State: _____________ Zip: _________________
Home Phone: __________________________ Emergency Phone: ________________________
Family Insurance Carrier:
______________________________________________________________
Policy #:
______________________________________________________________________________
Participant Signature: ________________________________________ Date: ______________
Parent/Guardian Signature: __________________________________ Date: _______________
For Office Use Only: Date Received: ______________________ Congregational ID #: ________________
Does the participant have any conditions that would prevent him or her from participating in
any Youth Gathering activities? If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
Health History
(Please complete so that health providers can be aware of your needs)
Pre-existing medical conditions:
Current Medications:
Allergies to food, medication, or environment:
Please photocopy the front and back of participant/cardholder’s insurance card and attach to
this form, please also indicate anything else that leaders should know to help avoid or assist
in any medical situation that might arise.
For Office Use Only: Date Received: ______________________ Congregational ID #: ________________
Forms – Covenant of Conduct
(Every participant must complete and sign this form)
I understand that during the 2014 Western States Youth Gathering, under the guidance of my
church and as a representative of Christ and the Christian community, I am responsible for my
own actions.
1. I intend to participate in all activities.
2. I will respect other participants at this event and treat them as fellow members of the
Body of Christ.
3. I will respect and appreciate the different gifts, cultures, and perspectives encountered
at WSYG 2014.
4. I will respect the property of others.
5. I will not abuse my body with drugs or alcohol at any time or have possession of these
substances.
Should I break this covenant, I agree to accept the consequences of my action. If it is
determined by my Church Leaders and in agreement with WSYG Leadership that my behavior
warrants my leaving this event, travel to my home will be at my own expense or that of my
parents/guardians.
Signature of Participant: ____________________________________________________
Date: ______________
Signature of Parent and/or Guardian: __________________________________________
Date: ______________
Signature of Adult Counselor: _________________________________________________
Date: ______________
For Office Use Only: Date Received: ______________________ Congregational ID #: ________________