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t e r W h ite Wa s h Early Bird Reg.

Fee: $55 per person
Win 2 11
Early Bird Total Fee: $110 per person
At Door Fee: $130 & No-T-shirt
January 21-23, 2011
*Early Bird Registration Fee is NON-REFUNDABLE!
Participant Registration Form Postmark Deadline: December 17th, 2010
Print Clearly

Name: __________________________________________________________
(Last) (First) (Middle)

City:____________________________________ State: ______ Zip:_________
Telephone:_________________________ Age: ________ Male____ Female _____
Church Home/Sponsor: _______________________________________________
Email address: _____________________________________________________

Name: ______________________________ Relationship:__________________
City:____________________________________ State: ______ Zip: _________
Work Phone: ____________________ Cell/Home Phone: ____________________
Any Health Concerns We Need To Know? ___________________________________
Roommate Preference: (4 people per room) One Sponsor/Staff Per 7 Students - Minimum
1.)___________________________ 2.)_____________________________
3.)___________________________ 4.)_____________________________
Are you staying at the Hotel? Yes No ($20 off of fee)
Need Rental? Yes No ($10 off of fee) If yes, what? Skis Snowboard
*Long Sleeve T-Shirt Size*: Small Medium Large X-Large XX-Large XXXL
Need Lift Ticket? Yes No ($20 off of fee)
Need Lesson? Yes ($10 Additional Fee) No
If Yes, Do you need a Ski or Board Lesson? Ski Board
CCC Office Use Only
Pre-Registration Fee Paid:________ Date Received:_________ Discounts: No Hotel __ No Lift __ No Rentals __
Money Owed at Registration: __________________ Additional Fee For Ski or Board Lesson ____________
Registration Fee Paid: _________ Date Received: _________ Total Fee With Discounts and /or Additions: ________
hit e Wa sh
Winter W 2 11
Parental Consent & Medical Treatment Form
Name of Church:_____________________________________________

Youth Leader:________________________________________________

We/I, ______________________________________________, the parent(s) or legal guardian(s) of
___________________________________, certify that we/I have been informed that our/my child will be
participating in Winter White Wash, sponsored by Central Church of Christ which may carr y with it
a certain degree of risk. Winter White Wash might include swimming, hiking, camping, field trips,
sports, skiing, and other activities offered by the church. We/I consent for my child to participate
in these activities. By signing this form we/I will not and can not hold Central Church of Christ,
employees of and or sponsors of Central Church of Christ and Winter White Wash responsible for
any accidents occurring at, en route, or near the event. I affirm that my child is physically fit and
has the necessary skills to safely par ticipate in these activities.
I, the undersigned parent or guardian of ________________________________, a minor, do hereby
authorize adult workers with the youth of Winter White Wash to consent to any examination, x-ray,
anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under
supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act
on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at
the office of said physician or at said hospital.
Further, as parent or guardian of the minor named above, I do hereby expressly consent
that my son/daughter may receive emergency medical treatment from any physician, hospital, or
other medical center without the necessity of first notifying me, and do further agree to hold
blameless any physician, hospital or other medical center for rendering such services.

Insurance Company or Group: ____________________________________________________________________________
Policy Number: ____________________________________________________________________________________________
Name of Policy Holder: ___________________________________Social Security Number:______________________

(Please print the following information)
Name of Participant: _____________________________________________________
Parent or Guardian: ______________________________________________________
Address: __________________________________________________________________
City: _____________________________ State: _____________ Zip: _______________
Daytime Phone: ______________________ Evening Phone: __________________
________________________________________ __________________________________
Signature of Parent or Guardian Date
My signature confirms that I hereby give witness to the proper completion
of this form by the minor’s parent or guardian.
W h ite W a sh
Winter 2 11
Code of Behavior
The following guidelines are established for your safety and to insure the full
enjoyment of Winter White Wash 2011 for you and every one attending.
1. Keep your mind on your relationship with God. He is the reason you are here. Plan
time to listen for what He is trying to say to you.
2. You are responsible to the adult leaders from your church and the White Wash Staff.
3. You are a guest at the Days Inn. You represent yourself, your church and
your Lord. Respect the needs of other guests. Take care of the Hotel property. You are
financially responsible for any damages. We want to use this location for years to come.
4. Be on time to all White Wash 2011 events.
5. You are required to stay in your room after “lights out”. NO EXCEPTIONS.
6. A NO TOLERANCE rule applies to guys in girl’s rooms and girls in guy’s rooms.
You will be sent home immediately.
7. You must ride with your church group for all activities unless approved by your sponsors.
8. A NO TOLERANCE rule applies to alcohol, drugs, fireworks, water balloons, or tobacco
9. Failure to follow these guidelines can result in your immediate dismissal from
Winter White Wash 2011 without a refund. It is the responsibility of the church sponsor or
family to provide transportation home due to dismissal.

I understand and agree to all the guidelines listed above. I understand that
violating any of them can result in my immediate dismissal from Winter White
Wash 2011.
Student Signature __________________________ Date ____________

Parent/Guardian Signature ______________________ Date ___________

No one will be admitted to Winter White Wash 2011 without this signed agreement.