Journeymen Out-Groups

Riverlink & Journeymen: Preserve the French Broad!

June 18 2-5 at Azalea Park

July 18 11-2 at Charles D. Owen Park

Participant Information

First Name

Last Name

Email Address

Cell Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Age of participant currently?

12 - 14

15 - 17

Parent's Information

Parent's First Name

Parent's Last Name

Parent's Email

Parent's Phone Number

Confidential Medical Questionnaire

If you become ill or injured during these groups, you authorize us to share this information with medical personnel. Otherwise, all information will be kept strictly confidential.

Will the participant taking any medication (prescription or nonprescription) that will be required during these groups?

Yes

Please List Medications, how much (mg), how often needed, and current side effects

Emergency Contact Full Name & Relationship

Emergency Contact Phone Number

Do you have health insurance

Yes

Insurance Company

Policy Number

Insurance Co. Phone Number

Do you have any medical or psychological condition that would affect your participation in the groups?

Yes

If yes, please explain:

In case of medical emergency please list specific instructions:

Please list food allergies and/or food sensitivities and label as such.

Consent Disclaimer

I consent that Journeymen may photograph and videotape parts of the groups in order to promote future Journeymen events. By signing and returning this form I give my or my participants' consent to Journeymen (this is a voluntary request).

• I agree that participants may be interviewed, recorded and photographed by Journeymen or any person Journeymen mandates to that effect.

• I accept that Journeymen may or may not use participants name, image and likeness in any verbal presentation, conference, interview and written publication.

• I recognize that Journeymen shall have the exclusive rights to the materials indicated above, including copyrights and proprietary rights, and I assign to Journeymen any right in relation to the materials.

• Journeymen may not assign or transfer, in whole or in part, the rights granted by the present contract.

Consent

Release & Acknowledgement of Risks

I have read and agree to the Terms and Conditions.

Adult/Guardian Name

Payment

Participation Fee: The $25 participant fee covers activity costs, as well as supplies and some administration fees. Our groups are driven by many volunteer hours. We do not want finances to be a barrier for you and will work with you to make the community groups accessible. Additionally, we ask those who can to pay it forward to help cover the costs of folks who may otherwise not be able to afford the full tuition.

Note: You will be directed to pay via PayPal when you click "Register and Pay" below.

Choose Payment Option:

Full Tuition: $25

Please Contact Me To Make Payment Arrangements

Riverlink & Journeymen: Preserve the French Broad!

Confidential Medical Questionnaire

Consent Disclaimer

Release & Acknowledgement of Risks

Payment

Rites of Passage

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