Indian Lakes Resort 250 West Schick Road, Bloomingdale, IL 60108 630-529-0200 Friday, October 25 Sunday, October 27,

27, 2013

Registration Form
(Please Print - one form per person. Make as many copies as needed)

Name:______________________________________ Age:_______ T-Shirt Size: XS S M L XL XXL Address: ______________________________________________________________________________ City: _______________________________________ State: _____________ Zip: ___________

Parent/Legal Guardian Name: ________________________________Cell Phone: ________________

Parent/Guardian Email address: ________________________________ Home Phone: __________________

HEALTH INSURANCE COMPANY: ____________________________________________________ POLICY NUMBER: ___________________________________________________________________ KNOWN ALLERGIES/MEDICAL CONDITIONS: ________________________________________
As a registered participant I agree to abide by all guidelines and rules as set forth by MISSION ALIYAH INTERNATIONAL INC., NFP - 2013 Purity IS Popular Leadership Summit for my protection and overall safety of the event. Failure to do so may result in disciplinary action and/or being sent home. I agree to participate in all event activities as health or other factors allow and present myself in an appropriate (dress, actions & attitude) manner. I further agree to allow my physical representation to be used in pictures or video for purposes of promotion, etc. I indemnify, defend and hold harmless MISSION ALIYAH INTERNATIONAL INC., NFP - 2013 Purity IS Popular Leadership Summit CORE STAFF, VOLUNTEERS, ACCOUNTABILITY LEADERS from all claims made and liabilities assessed against them as a result of the registrants activities. Further, in case of emergency, I understand that every effort will be made to contact parents or guardians. However, if parents or guardians cannot be reached, I, the parent or guardian hereby give MISSION ALIYAH INTERNATIONAL INC., NFP - 2013 Purity IS Popular Leadership Summit CORE STAFF, VOLUNTEERS, ACCOUNTABILITY LEADERS permission to act on my behalf in seeking medical treatment in the event that such treatment is deemed necessary or advisable for the registra nts health, safety and welfare. I give permission to those administering medical treatment to do so, using the measures deemed necessary. I release MISSION ALIYAH INTERNATIONAL INC., NFP - 2013 Purity IS Popular Leadership Summit CORE STAFF, VOLUNTEERS, ACCOUNTABILITY LEADERS and MEDICAL PROVIDERS from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from the registrant s activities.

__________________________________________________________________________ Attendees Name (Print & Sign) __________________________________________________________________________ Parent/Guardian Signature

_____________________________________ Date _____________________________________ Date

FOR OFFICIAL USE ONLY: $75.00 REGISTRATION PAID? Y __ N___ HOTEL RESERVATIONS MADE? Y __ N___ ROOM OCCUPANCY: SINGLE ___ DOUBLE ___