FIFUL.org | "TRUE” – The REAL Urban Experience

"TRUE” – The REAL Urban Experience

Please read the following information and confirm your commitment to participate:

In committing myself to this project, I pledge to fulfill the following:

To participate in the whole project, and pay the entire fee of $100.00.

To adopt the posture of servant and learner. To be a team player.

To adopt a positive attitude, avoiding complaining or grumbling or things that would undermine community or relationships.

To go to bed when asked and by midnight even if not asked.

1. In consideration for being accepted and allowed to participate in this conference/project and activities associated with its program and location, I personally assume responsibility for my actions, and release InterVarsity Christian Fellowship/USA® (hereafter InterVarsity®), its Trustees, employees and agents from loss, injury or damage to myself or my property; provided that nothing contained herein shall excuse InterVarsity, its Trustees, employees or agents from responsibility to act with reasonable care for the safety of myself or my property.

2. I give permission to InterVarsity to be photographed, recorded, and/or video taped and to allow this material to be used for publicity.

3. I give permission to InterVarsity to obtain medical assistance in the event of an emergency. This permission will include the administration of medicines, surgical treatment, X-ray examination or hospitalization as might be ordered by a licensed medical doctor. I release and discharge InterVarsity, its trustees, employees, and agents from any liability for any first aid rendered or treatment performed pursuant to this consent.

4. I understand that InterVarsity has a hostage policy that states that InterVarsity should not yield to demands, including the payment of ransom or other extortion, issued through the use of hostage taking or extortion.

5. If I am under age 18 (if you are, please check here ), I state that I am a mature minor (of college age and living away from parent/guardian) and have the capacity to consent to the terms of the Release.

6. Any claim or dispute arising from or related to this release shall be settled by mediation and if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, a division of Peacemaker® Ministries (complete text of the Rules is available at www. HisPeace.org). Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction. I understand that these methods shall be the sole remedy for any controversy or claim arising out of this release and expressly waive my right to file a lawsuit in any civil court against InterVarsity for such disputes, except to enforce an arbitration decision.

By typing my full name in the following box:

I certify that I have read the above information and am competent to submit this release, and have done so voluntarily.

Full Name:
Gender:	Male Female
Address:
Apt:
City:
State:
Cell Phone:
Email:
Are you currently taking medication for depression or under a doctor's care?
	Yes No
Have you at any time within the last 3 years attempted suicide?
	Yes No
Date of Birth:
School:
Year in School:
Major:
T-Shirt Size:
Emergency Contact Information
Name:
Phone:
Relationship:
For the following questions, type YES or NO to the questions. If YES, please explain.
Do you have any Medical concerns we should be aware of?

Do you have any allergies or medical conditions staff should be aware of to avoid problems and to assure proper emergency action?

List the names of any medications you are taking or have been taking in past month.

Do you have any food restrictions that staff should be aware of to avoid problems?

Do you have any medical conditions that could affect your participation in this project? Type YES or NO. If YES, what are those concerns?