Corban Experience Registration

Personal Information

First Name *

Last Name *

Street Address *

Address (cont.)

City *

State *

Zip/Postal Code *

Home Phone *

Email *

Student Cell Phone *

Gender *

Male

Female

What Church do you attend?

Parents

Lunch passes needed for parent(s)

Educational Information

High School

Waiver of Liability

In consideration of my participation in the activities of Corban Experience, on behalf of myself, the undersigned Participant and Parent or Guardian hereby release, waive, and discharge Corban University (including its officers, employees, volunteers, and agencies) from liability for injury, loss, or death to the minor, while participating in the activities of Corban Experience.

In case of EMERGENCY CARE – I authorize or agree:

Corban University to administer emergency first aid, CPR, and use an AED when deemed necessary by Corban University.
Corban University to secure emergency medical care or transportation (i.e., EMS) when deemed necessary by Corban University.
Corban University to share my medical history with emergency medical personnel when deemed necessary by Corban University.
To assume all cost of emergency medical care and transportation.

Emergency Contact 1

Name

Relation

Phone Number

Emergency Contact 2

Name

Relation

Phone Number