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Winter Weekend Registration/Participant Information and Release Form
Fellowship, Devotions, & Fun (indoors and/or outdoors). 2 nights lodging & 5 meals included. This event takes place at The Au Sable Institute which provides bunk-house style lodging, meals and equipment (XC Skis, snowshoes, sleds, broom ball). Bring your own bedding!! It's a great time to play together, fellowship together and worship together. You can spend your time outside or inside--there is no required schedule other than meals and Worship times. Worship times on Saturday evening and Sunday morning are casual and meaningful. Come ready for a great time! On-line registration "sign-up" is open--and registration along with full payment of $95 will reserve your spot.

Please take a few minutes to complete this form and digitally sign the release. Every participant must submit this form prior to participating in an Au Sable Institute program.

Program Description and Dates:
Jackson Free Methodist Church Winter Weekend at Au Sable Institute January 25, 26, 27, 2019 If you have any questions you can email Liann at crydermanb@gmail.com

Participant's First Name *
Your answer
Participant's Last Name *
Your answer
Best Email Address *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Birthday *
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Name of Emergency Contact *
Your answer
Best Phone Number of Emergency Contact *
Your answer
Relationship to you of Emergency Contact *
Your answer
Participant's Health: Please list any physical or medical conditions, medications taken, allergies or other information that would be helpful to medical responders in the event of an emergency.
Your answer
Do you have any dietary restrictions (food allergies, vegetarian, dairy products)? If yes, please describe:
Your answer
Ride Sharing--I understand I am responsible for my own transportation to and from Au Sable Institute. Please check all that apply
Description of Program
Au Sable’s Winter Retreat Facility is an outdoor oriented program run by Au Sable Institute of Environmental Studies. The
program takes place at the Au Sable Institute’s campus near Mancelona. The Retreat involves activities of a physical
nature that will take place in an outdoor environment. Participation may involve the following, but is not limited to these
activities: service oriented work projects, hiking on trails and in the vicinity of frozen bodies of water, Snow shoeing,
Cross county skiing, sledding, and Broom ball.
Required Signature
Participants cannot take part in any Au Sable program without signing the following release.

Assumption of Risk and Agreements of Release and Hold Harmless
I acknowledge that I have read and understand the description of this program and have noted any medical or physical
conditions that might affect the participant’s performance in this activity. I understand that this program involves known
and inherent risks, as well as unknown/unanticipated risks. Inherent risks may include those ordinarily associated with
physical activity in outdoor environments.

In consideration for Au Sable Institute permitting me or my child to participate in this program, I hereby, for myself, my
heirs and survivors, release Au Sable from all personal injury, property damage, loss of personal property, or any other
loss sustained by me or my child while participating in this program, including travel to and from the program site, and
agree to hold harmless Au Sable and its employees, representatives and volunteers from any and all claims made by me,
my child or my heirs and survivors. In case of accident or illness I will bear the cost of all emergency procedures and
medical care.

Release Authorization for Medical Treatment for Minors
If the participant is under the legal age of consent (18 years), the law requires that we have a parent’s permission to give
medical service should the need arise.

The undersigned, who is one of the parents having legal custody, or the legal guardian, of the minor participant named
above, hereby gives permission to personnel of Au Sable Institute to authorize any X-rays, tests, procedures, anesthetic,
surgery or treatment on behalf of, and to provide or arrange for any transportation of, participant as may be required in
the event of an emergency. I authorize Au Sable personnel, if necessary, to administer epinephrine via Epi-Pen injection
for emergency treatment for anaphylactic shock. If the emergency contacts designated on this form cannot be timely
contacted, I hereby give permission to a licensed physician, or other qualified health care provider as may be appropriate,
to administer such treatment to participant as may be necessary under circumstances, including hospitalization of the
patient. I also agree to assume any financial responsibility for my child’s care.

Photo Release
I authorize and consent to Au Sable Institute taking photographs and video film of the participant in its
programs, and to the unrestricted use and publication of such photos or videos to promote the activities of Au
Sable Institute. (No names will be used without obtaining prior written consent.)

I HAVE READ THE AGREEMENT, FULLY UNDERSTAND IT AND GRANT PERMISSION FOR ME/MY CHILD TO PARTICIPATE IN THE PROGRAM IDENTIFIED ABOVE. THE UNDERSIGNED ALSO UNDERSTANDS THAT PARTICIPATION BY ME OR MY CHILD WOULD NOT BE ALLOWED WITHOUT THIS PROVISION.
I confirm that I have read the above information *
Required
If Participant is Under 18
Name of parent or legal guardian signing and relationship to participant:
Your answer
If Participant is 18 and over
Full name of person 18 and older
Your answer
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