State Retreat - Youth Form | Colorado DeMolay

Full Name of Registrant *

Parent/Guardian's Full Name *

Phone *

Address *

Email Address *

Birthdate & Age *

Home Chapter *

Dietary Requirements, i.e. kosher, vegetarian, gluten free, etc. *

Rules/Approvals/Consent/Release

Consent Release Statement *

By simply registering online for Colorado State Retreat 2021, you hereby agree, on your own behalf and/or as the Parent or Legal Guardian of the Participant at Colorado State Retreat, the participant will conform to and abide by the statutes, rules, regulations, and edicts of DeMolay International, Jurisdiction of Colorado, the staff, DeMolay representatives, our sponsors, and all rules and regulations applying to the Colorado State Retreat event. By your acceptance of this online registration, you hereby agree that if in the event that an advisor, the Colorado Event/Convention Director, State Staff, or the Executive Officer have determined you need to be removed or asked to leave any activity for violation of the rules, the participant and/or parents will immediately take all necessary action to cause the transportation of violator from the site at the sole expense of the member and/or parents. By registering online for Colorado DeMolay State Retreat 2021, you agree and acknowledge that participation in DeMolay activities involves a certain degree of risk. You have decided to register and have given your consent for yourself and/or your child to participate in these activities. Your acceptance of online registration and this online registration form gives your approval and understanding that participation in these activities is entirely voluntary and requires participants to abide by the applicable rules and such acceptance of this online registration, you further release the Chapter, the Jurisdiction of Colorado, DeMolay International, active members, employees, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this event.

Consent-Release Electronic Signature - Type full name, if under 18 parents full signature is required. *

Sign Date *

Month

Day

Year

Media Release

Media Release Statement *

I grant permission to the jurisdiction of Colorado and its subordinates, including all Chapter(s) and related organizations to use my photo for use in DeMolay publications such as recruiting brochures, newsletters, and magazines, and to use my name and/or photographs on display boards, any photographs in electronic versions of the same publications or on the Colorado DeMolay website or other forms of social media.

Media Release Electronic Signature - Type full name, if under 18 parents full signature is required. *

Full name signature

Media Sign Date *

Month

Day

Year

Emergency Information

Allergies *

Physical Handicaps *

Emergency Phone #1 *

Emergency Phone #2 *

Medication Information

Medications Currently Being Taken - All medications and daily dosage MUST be listed *

Medical Release and Consent

Medical Release and Consent Statement *

Medical Electronic Signature - Type full name, if under 18 parents full signature is required. *

Medical Sign Date *

Month

Day

Year

Medical Insurance Info

Medical Insurance Provider *

Medical Insurance Provider Phone Number *

Name of Policy Holder *

Policy Number *

Parent Permission and Release

Permission Statement *

Youth will not be allowed to participate without a permission slip signed by your Parent/Guardian on file. I give permission for my child to join the DeMolay of Colorado, in the activities sponsored by the State Organization, its staff, and sponsors. I hereby release them from responsibility and liability from any/all illness or injury that my child may sustain during this activity/event. In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me, to consent to an x-ray examination, medical, dental or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, dentist (as appropriate), licensed to practice under the laws of the state where the services are rendered, either at a doctor's office, urgent care facility, or in any hospital. I will expect to be contacted as soon as possible.

Permission signature - Type full name, if under 18 parents full signature is required. *

Parent permission signature

Permission Sign Date *

Month

Day

Year

E-sign statement *

My signature below serves as my full understanding and confirmation that I have electronically signed and agreed to all portions of this registration.

Electronic Signature

E-sign signature - Type full name, if under 18 parents full signature is required *

E-sign Date *

Month

Day

Year

Agreement to Guidelines and Waivers

Agreement to Guidelines *

I have read and agree to all of the Guidelines for this event.

Registration Parent Signature - Type full name, if under 18 parents full signature is required *

Registration Sign Date *

Month

Day

Year

Building tomorrow’s leaders today, since 1919.

State Retreat - Youth Form

Youth Registration-State Retreat 2021

STATE RETREAT 2021 REGISTRATION

Rules/Approvals/Consent/Release

Media Release

Emergency Information

Medication Information

Medical Insurance Info

Parent Permission and Release

Electronic Signature

Agreement to Guidelines and Waivers

You are here

State Retreat - Youth Form

Youth Registration-State Retreat 2021

STATE RETREAT 2021 REGISTRATION

Rules/Approvals/Consent/Release

Media Release

Emergency Information

Medication Information

Medical Release and Consent

Medical Insurance Info

Parent Permission and Release

Electronic Signature

Agreement to Guidelines and Waivers