Individual Registration Is this registration associated with a group registration?YesNoGroup NameOur records show that you are following up on a group registration with the following group of men. If this does not seem correct, please contact your group organizer or email us at firstname.lastname@example.orgGroup Organizer's Email Who will pay registration balance?ParticipantGroup OrganizerPersonal InfoRegistration IDName* First Last Email* Enter Email Confirm Email Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneHome CongregationCity of Home CongregationRegistration OptionsAttendance*Extended Retreat (7 meals, 3 nights, basic programs)Full Retreat (5 meals, 2 nights, basic programs)Saturday Only (3 meals, most basic programs)HousingWhere would you like to stay?*Update (March 20, 2019): Space in the lodge is now very limited. We may not be able to honor roommate requests.LodgeCabinTentRoommate Requests Are you able to sleep on a top bunk?*YesNoActivitiesSpecial Activities Medieval Challenge Archery Tag Friday Afternoon Mini Golf Tourney Saturday Bass Fishing Tournament 3G Extended Activities (Friday 8:00 am – 3:00 pm)Please note that our $12 charge for these extended activities covers the cost of breakfast and lunch on Friday. We will not cover additional costs associated with these activities (gun rental, ammunition, course fees, transportation, etc.) will be covered by participants. You are only able to select one of these 3G extended activities. Gun Range Golf Outing Giving Back (service project) Registration DuesThe Growler Discount I would like to receive the early registration growler discount. Individual Registration DepositThis is the amount that will be paid when you submit this registration. Price: $20.00 Please note that your deposit has already been paid by your group leader.Estimated TotalThis is the your estimated total registration cost. Final cost is dependent upon which housing you are assigned. $0.00 Estimated Total (Copied)Estimated Balance DueMedicalIn case of an emergency, this form will be used to accurately, safely, and effectively treat you.Authorization of Medical & Dental Treatment*I authorize the Men’s Gathering staff (and/or any other qualified person appointed or designated by them) (1) to provide routine healthcare, (2) to employ physicians, surgeons, dentists, nurses, and any other healthcare personnel as may be deemed necessary if I am otherwise unable, (3) to sign all necessary consents and authorizations. It is understood that this authorization is given in advance occurrence of any condition or situation that would necessitate any such medical, surgical, dental care being required; but is given to provide authority to obtain such care if it should be required. I full understand the consequences of the foregoing statements and sign this AUTHORIZATION OF MEDICAL/DENTAL TREATMENT knowingly, freely, and willingly. By checking here, I signify my agreement to the above-mentioned authorization. Emergency ContactPerson to contact in case of illness or injuryName* First Last Relationship to Participant*Best Contact Phone Number*InsuranceInsurance CompanyInsurance Company PhonePolicy NumberGroup NumberSubscriber Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Attach a copy of your medical insurance card to this form. Drop files here or Accepted file types: jpg, png, pdf, jpeg. Health HistoryDo you have any allergies (medications, foods, bee stings, etc.)?Have you had any surgery recently?Do you have any restrictions of activity for medical reasons?LegalRelease, Indemnification, and Hold Harmless Agreement*I execute this Release, Indemnification and Hold Harmless Agreement (“Agreement”) on my behalf in regard to the 2019 Men’s Gathering (Gathering) being held at Lakeview Ministries on the dates of April 7 – 9. I certify that I am at least 18 years of age and have full legal authority to execute this Agreement on behalf of myself, my family, my heirs, representatives, successors, executors, administrators and assigns. I agree, on behalf of myself, my family, my heirs, representatives, successors, executors, administrators and assigns, to FOREVER RELEASE, INDEMNIFY, DEFEND, AND HOLD HARMLESS the organizers of the Men’s Gathering (Organizer) and South Central Lutheran Camp Association of Indiana, Inc., doing business as Lakeview Ministries, and its agents, servants, employees, volunteers, patrons, officers, and directors (collectively, “Lakeview”), from any and all actions, claims, demands, suits, liabilities, assertions of liability, losses, costs, judgments, and expenses, including but not limited to attorney fees, reasonable investigative and discovery costs, and court costs, which in any manner may arise or be alleged to have arisen, or resulted, or alleged to have resulted, from (i) the participation of myself, or (ii) the presence, activities, acts or omissions (whether negligent, intentional, or otherwise) of the organizers of the Men’s Gathering and Lakeview. This includes, but is not limited to, all actions, claims, demands, suits, liabilities, assertions of liability, losses, costs, judgments, and expenses on account of personal injury, property damage, death or accident of any kind, arising out of or in any way related to the participation in Gathering, however the injury or damage is caused, including but not limited to, the NEGLIGENCE of Organizer and/or Lakeview. I fully understand and acknowledge that certain elements of Gathering may be physically hazardous and that by participation in Gathering, I may face the risk of accidental and/or other injury. There risks include, but are not limited to, (i) loss or damage to personal property, (ii) injury or fatality due to and/or related to walking, running, jumping, swimming, handling athletic equipment, horseback riding, zip lining and/or other physical activity, (iii) head, neck, arm, leg and/or back injuries, (iv) exposure to inclement weather, outdoor terrain and all the risks inherent therein, (v) slips and falls, and (vi) any other aspects related to Gathering. I have fully investigated the nature of Gathering and assume the risks of my participation in Gathering. I agree that my participation in Gathering is entirely voluntary and that I am not under any obligation to take part in Gathering. I am fully aware that I may suffer these or other injuries arising out of participation in Gathering. However, I voluntarily assume these risks so that I may participate in Gathering. This Agreement is to be governed by and construed under the laws of the State of Indiana. In the event that any term or provision of this Agreement is found to be unenforceable or void, in whole or in part, the term or provision concerned shall be construed as valid and enforceable to the maximum extent permitted by law, and the balance of this Agreement shall remain in full force and effect. I agree that exclusive venue for any dispute arising between Gathering and/or Lakeview and me involving this Agreement shall be in Bartholomew County, Indiana. By checking here, I signify my agreement to these terms. Additional NotesIs there any additional information you would like to share with us? Is there anything we should now about about your registration or your attendance?Payment DetailsCredit Card* Card Details Cardholder Name NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.