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Name

First

Last

Address

Address Line 1

City

State

Zip Code

Phone

Email - IF YOU DON'T HAVE AN EMAIL ADDRESS USE mychurch@mymthebron.org

Attendee #1

Full Name

attendee1_name

Age

attendee1_age

Sex

attendee1_sex

Shirt Size

attendee1_shirt_size

THE of

Attendee #2

Full Name

attendee2_name

Age

attendee2_age

Sex

attendee2_sex

Shirt Size (copy)

attendee2_shirt_size

Attendee #3

Full Name

attendee3_name

Age

attendee3_age

Sex

attendee3_sex

Shirt Size

attendee3_shirt_size

If paying by check or money order Mail To: Mt Hebron Baptist Church 3445-47 West Douglas Blvd, Chicago, Il 60623, within 3 days of submitting this form. You may also pay by debit or credit card. (Text 77977, message-mthebronmbc, follow the prompts, select Retreat. If paying by debit or credit card, please include the name on the card here

Adult Participate: Please list roommate(s)

IF THIS IS YOUR FIRST TIME ATTENDING THE RETREAT, PLEASE INDICATE THE NAME OF THE PERSON WHO INVITED AND/OR TOLD YOU ABOUT THE RETREAT

AUTHORIZATION FORM

The Mt. Hebron Missionary Baptist Church is sponsoring a religious retreat at Cedar Lake Ministries, 13701 Lauerman St., , Cedar Lake, IN 46303 from June 18 – June 21, 2025. I understand this document is an authorization granting the church permission to take the above named individuals to the retreat. Full authority is granted to Mt. Hebron to supervise and instruct the same. I do further agree to indemnify, protect and hold harmless said church, its officers, board members, supervisors, agents, servants, employees and all private persons or organizations to supervise or chaperone minor participants in this retreat excursion while engaged in this retreat (and its activities) including travel to and from, from any claim or liability whatsoever, including but not limited to, personal injury, property damage, court costs, attorneys’ fees and interest, however caused, as a result of the minor participating in the religious retreat.

I further agree to pay for all damages caused by the above named individuals to the retreat facility or the bus, as well as any injuries/illnesses sustained by or caused by the same.

I hereby authorize Mt. Hebron Missionary Baptist Church and its designated representatives to obtain reasonable medical care and emergency services in case such circumstance presents itself. I further hold harmless Mt. Hebron and its representatives of any liability due to such medical care and emergency service as provided.

I further agree that Mt. Hebron, its officers, agents, and/or employees reserve the right to terminate the participation of the minor for failure to behave and act in accordance with the church’s regulations and instructions on conduct, for failure to follow instructions and directions of the retreat supervisors and/or chaperones, or for any acts of the minor deemed by the board, its officers, agents, and/or employees to be detrimental to or incompatible with the interest, harmony, comfort or welfare of the retreat as a whole. If the participation of the minor is terminated, the minor shall be escorted home at the expense of the parent or guardian. No refunds will be granted.

I further agree Mt. Hebron, its officers, agents and/or employees reserve the right at any time prior to or during the retreat, to make cancellation, changes or substitutions in emergencies or changed conditions or in the interest of the group, and to alter, prior to the retreat departure to meet unexpected changes in fares, hotel rates, etc.

Refund policy: I understand and agree that if Mt. Hebron cancels the retreat for any reason, refunds will be granted. However, if I should have to cancel for any reason, no refunds will be granted after June 1, 2025.

Type Name of Parent/Guardian/Participant (if under the age of 18)

Emergency Contact Name

Emergency Contact Phone Number

Emergency Contact Address

Address Line 1

City

State

Zip Code