WHAT? Momentum
WHERE? Flint Central Church of the
Nazarene
WHO? 7th-12th Grade
DEPART? Friday, Feb 5, 2016, 5pm
RETURN? Saturday, Feb 6, 2016, 6pm
COST? $45 (due 1-10-15, non-refundable)
registration, food (Friday dinner,
transportation,
housing)
Saturday
breakfast & lunch),
Sports: 5K Run, basketball (3-on-3, free throw,
hot shot), volleyball, soccer (co-ed), table tennis.
Register for golf, tennis & home run derby which
take place at Celebrate Life.
Music: Vocal (solo, duet, trio, ensemble, choir,
rap, praise band), instrumental (keyboard solo,
instrumental solo/duet/trio, ensemble, band)
Mind Competitions: Science quizzing, chess.
Arts: Painting, drawing, sculpture/crafts, still
photography.
Communications: Drama, mime, puppetry, dance, speech/reading, creative
writing, Bible exposition/Preaching, video production.
*You may enter more than one event, see registration form.
Momentum is the qualifier for Celebrate Life @ Olivet Nazarene University, May 12-14, 2016
Cost: Approximately $130
What is it: Momentum super-sized! with participants from Michigan, Wisconsin, Indiana and Illinois
in all the above categories. You will make new friends and see old friends from these states while
participating in your events and just hanging out around campus. Best of all are the daily worship
services with top-notch speakers and worship bands.
Who can attend: 1) Anyone who receives an excellent or superior rating in Music, Arts,
Communications at Momentum. 2) Anyone who makes the district volleyball, soccer, basketball,
table tennis, bowling, Science quizzing or chess team at Momentum. 3) Anyone who signs up for
golf, tennis or home run derby at Momentum. 4) Anyone who runs the 5K at Momentum. 5) YOU even if you do not participate in an event, you can still attend and be a part of this great
experience.
Questions or concerns, contact the Student Ministries office at 810-227-6600 x35 or
studentministries@thenaz.org.
PARTICIPANT EMERGENCY & PERMISSION FORM
DEADLINE:
Activity Description: Momentum
Sunday, January 10th
Form & $45
(non-refundable)
Location: Flint Central Church of the Nazarene Date: February 5-6, 2016
Activity Cost: $45 (registration, transportation, housing, food) - non-refundable
Depart: 5:00 pm @ The Naz, Friday, February 5. Return: 6:00 pm @ The Naz, Saturday, February 6.
Sponsoring Organization: Brighton Nazarene Church, 7669 Brighton Rd., Brighton, MI 48116
Telephone: 810-227-6600x35 Name of Coordinator: Stu Shattuck
By signing below I herby give consent for him/her to participate with the above activity. I agree that I
have read the information given and fully understand that I am responsible for my child’s
participation and full payment. I agree that my child is committing fully to this trip and that should
he/she decide to back out, I am still responsible for the full payment to cover the cost of their spot.
Participant Emergency Information
(To be completed by Participant or an authorized Parent/Guardian)
Full Name of Participant: _____________________________________________ Birth Date: ________________ Grade:____
Participant's Street Address:_________________________________City:_____________________State:_____Zip:_________
Participant's Home Phone: ____________________________ Participant Cell Phone:_______________________________
Participant E-mail Address: _____________________________________________________________________________________
Full Name of Parent/Guardian: _________________________________________________________________________________
Parent/Guardian Street Address:_______________________________City:__________________State:_____Zip:_________
Parent/Guardian Home Phone: __________________________Parent/Guardian Cell Phone: _____________________
Parent/Guardian E-mail Address: ______________________________________________________________________________
Emergency Contact other than Parent/Guardian: ____________________________________________________________
Telephone number #1: __________________________________________ #2: __________________________________________
Is Sponsor Coordinator authorized to approve medical treatment if Parent/Guardian or Emergency
Contact isn't available? _______ Yes _______ No
Is Participant covered by medical insurance? _______ Yes _______ No
If yes, name of insurer: __________________________________________________________________________________
Policy or group number: ________________________________________________________________________________
Participation Agreement
By signing below, the Participant acknowledges and accepts the risks of physical injury with
participation in the activity described above. Except for gross negligence on the part of the Sponsor
Coordinator, the Participant accepts personal financial responsibility for any bodily or personal injury
sustained during the activity. Further, the Participant promises to hold harmless the Brighton Nazarene
Church and its representatives 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: _____________________________________________________________ Date:_____________________________________
(Participant or Parent/Guardian if Participant is a minor)
SEE PARTICIPANTS COVENANT PROMISE – REVERSE SIDE
PARTICIPANT COVENANT PROMISE
I PROMISE ....
1. No drugs, alcohol, weapons of any sort (including pocket knives), or fireworks
(including sparklers, party poppers and snap pops).
2. No sexual activity of any kind.
3. No PDA (public displays of affection, hand holding, hugging, kissing).
4. No guys in girls’ rooms and no girls in guys’ rooms.
5. No guys and girls in the same seat in any vehicle.
6. Respect others and their property.
7. Be in rooms by curfew & no sneaking out after curfew, when curfew applies.
8. Stay in groups of no less than 3.
9. Check in with chaperones at designated times throughout event or trip.
10. When swimming; guys must wear shorts style trunks (no speedos) and girls must wear
one piece bathing suits. (Tankini’s are acceptable as long as they show no midriffs and
top is not low cut.)
11. No gambling of any kind.
 Remember that when you are at an activity with the Brighton Nazarene Church,
you are representing the church and you are representing God. You should do so
in a way that would be honorable and glorifying to HIM.



Any rule broken will result in a phone call home made by the student in which the
student will explain the situation to their parent(s).
Breaking rules could result in IMMEDIATE dismissal from the trip. The student will be
sent home at his or her own expense.
If sent home from any trip, the student will forfeit their opportunity to attend any future
events prior to meeting with the Student Ministries Pastor.
By signing below, you affirm that you have read and understand all of these Promises. You agree
to abide by these Promises while representing the Brighton Nazarene Church in any capacity.
You also agree to accept any consequence that will be enforced as a result of violation of these
Promises.
Participant's Full Name (Printed) _____________________________________________________________________
Participant's Signature________________________________________________ Date____________________________
Parent/Guardian Signature________________________________________________ Date_______________________
SEE PERMISSION & EMERGENCY FORM – REVERSE SIDE
MOMENTUM 2016 / Individual Registration Form
February 5-6, 2016
Student Information

Male
Name
Address
Female Age
Grade
City
Church you attend
MI Zip
Church of the Nazarene Adult / Sponsor
Cell Phone (
Shirt Size:

)

Extra Small
-

Small
Email

Medium


Large
Extra Large

2XL

Other
Parental Permission and Waiver of Liability
I hereby give authority to the NYI President (Jeff Tschetter) & the Celebrate Life Directors (Doug & Kandra Hewett) of the Eastern Michigan
District (EMD), to obtain minor medical attention or to authorize treatment at any hospital in the event of a medical emergency.
I also recognize the authority of all EMD MOMENTUM staff & district sponsors as those who will supervise this event and uphold proper conduct. I
understand that my son/daughter could be sent home and that I would be responsible for their transportation home and any destruction of
property.
I will not hold the Eastern Michigan District NYI or the Church of the Nazarene responsible for accident, injury, or theft. My son/daughter has my
permission to attend MOMENTUM 2016. I also understand no refunds will be given for this event.
Parent or Guardian Signature
Date
Home Phone (
)
Emergency Phone (
Work Phone (
)
Emergency Contact (
Insurance Company
/
/
)
)
(if possible, please include a scanned copy of insurance card)
Policy Number
Known Allergies
Student Agreement
I accept my responsibility to make MOMENTUM 2016 a safe, uplifting, and fun event for everyone there. I will follow the guidelines set by the EMD
NYI and am aware that failure to do so will result in disciplinary action. I also pledge to represent EMD in a positive way with whomever I come in
contact with including all adult sponsors, church personnel, etc. I understand that my eligibility to go to CELEBRATE LIFE at ONU could be
forfeited depending upon my actions at MOMENTUM.
Student signature
Date
/
/
Registration Costs
Registration (if postmarked by January 14, 2016 ) $25
If postmarked from Jan. 15 through Jan. 29, there is a $10 late fee
$25
$
If postmarked after Jan. 29 including walk-ins, there is a $25 late fee $
TOTAL: $
Checks are to be made payable to your local youth ministry or church.
If selected, I am able to compete at Celebrate Life at Olivet Nazarene University, May 12-14, 2016
YES
NO
MOMENTUM 2016 / Student Event Registration
Please check the appropriate box or boxes and circle the needed information. You may not enter any individual category more than once.
VOCAL MUSIC
.

SOLO - Accompaniment: CD / Tape / Live
Name of song__________________________
DUET - Accompaniment: CD / Tape / Live 
Name of song__________________________
TRIO - Accompaniment: CD / Tape / Live
Name of song__________________________
ENSEMBLE (4-11 members) OR
CHOIR (more than 12 members)
Accompaniment: CD / Tape / Live
Group name____________________________
Name of song___________________________

RAP: Solo / Duet / Trio / Ensemble
Name of song___________________________
PRAISE BAND 
Name of band__________________________
Name of song__________________________
(Please list separately the instruments & persons playing)
ARTS
.

PAINTING 
DRAWING 
SCULPTURE / CRAFTS
STILL PHOTOGRAPHY

COMMUNICATION
.

DRAMA
Group name_______________________________________
Name of piece_____________________________________
MIME
Group name_______________________________________
Name of piece_____________________________________
PUPPERTRY
Group name_______________________________________
Name of piece_____________________________________
SPEECH / READING

CREATIVE WRITING
INSTRUMENTAL
.

KEYBOARD SOLO: Piano / Organ
Name of piece__________________________
BIBLE EXPOSITION
INSTRUMENTAL: Solo / Duet / Trio
Instrument played_______________________
Accompaniment: CD / Tape / Live
Name of partner/s_______________________
EYM = Early Youth Male, EYF = Early Youth Female
SYM= Senior Youth Male, SYF = Senior Youth Female
(Early Youth = 7-8th graders, Senior Youth = 9-12th grader)
INSTRUMENTAL ENSEMBLE (4-11
members) OR
BAND (12 or more members)
Accompaniment: CD / Tape / Live
Group name____________________________
Name of song___________________________
(Please list separately the instruments & persons playing)
MIND COMPETITIONS

SCIENCE QUIZZING

CHESS
.
VIDEO PRODUCTION

SPORTS
.
5K Run 

BASKETBALL (3-on-3 HS tournament; optional sub)
Team name_______________________________________
Teammates_______________________________________
Please place me on a team
VOLLEYBALL
(tryouts only)
CO-ED SOCCER (tryouts only)

FREE THROW - EYM EYF SYM SYF
HOT SHOT - EYM EYF SYM SYF
TABLE TENNIS 

GOLF (register here, event only happens at CL)

BOWLING
TENNIS (register here, tryouts at CL)

HOME RUN DERBY (register here, event only happens at CL)