Helene Recovery in Western NC

Registration Options

Adult Team Member ($450.00)

Scholarship/Coordinator Code (If applicable.)

You may pay in full or pay a $225 deposit.

The $225 deposit is NON-REFUNDABLE.

The remaining $225 balance will be billed on May 10th, if not paid in full at the time of registration. All fees are NON-REFUNDABLE as of May 10th.

Some financial assistance is available. If you need this please reach out the The Rev'd Michelle Bullock or Emily Gowdy Canady BEFORE completing your registration.

About The Attendee

Attendee First and Last Name

Name You Go By

Attendee Email (The one you regularly check!)

Primary Phone Number

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Attendee Address

Attendee Gender

Pronoun Preference:

Attendee Date of Birth

Attendee's Parish Name

Attendee's Parish City

Priest or Warden's Name

Priest or Warden Email Address

Priest or Warden Phone Number

Attendee's T-Shirt Size

Date of Attendee's last Tetanus shot/booster

Participant Blood Type

Are you diabetic

Do you have a history of seizsures?

I feel healthy enough to fulfill the responsibilities of my mission team?

Any Physical Limitations, concerns, or other health information your team leader should be aware of?

Please list any necessary medical/health information (including ANY TYPE OF ALLERGY)

Please list any regularly taken medications and dosage

Please share any dietary, mobility, etc.

Other information that would be helpful for us to know

Admin Use Only

Attendee Medical Insurance Information

Parents/Guardians are financially responsible for all costs incurred, regardless of whether medical insurance coverage information is provided. All medical forms are shredded following each youth event.

Name of Insured

Insured Relation to Attendee

Insurance Carrier

Policy Number

Authorization Phone Number

Prescription Card Information

Please upload a copy of your insurance card if. you are providing this information.

Browse

PHOTO/MEDIA RELEASE

I hereby grant and authorize the Western North Carolina Conference of the United Methodist Church the right to take, edit, alter, copy, exhibit, publish, distribute, and make use of any and all video and pictures taken of me to be used in and/or for any lawful purpose. This authorization extends to all languages, media, formats and markets known or later discovered. This authorization shall continue indefinitely, unless I otherwise revoke this authorization in writing. I waive the right to inspect or approve any finished product in which my likeness appears. I agree that I have been compensated for this use of my likeness or have otherwise agreed to this release without being compensated. I wave my right to royalties or other compensation arising or related to the use of the video. I understand and agree that these materials shall become property of the Western North Carolina Conference of The United Methodist Church and will not be returned. I hereby hold harmless and release The Western North Carolina Conference of The United Methodist Church from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf.

Confidentiality Agreement

Confidentiality Agreement: As a volunteer or employee of the Western North Carolina Conference, Southeastern Jurisdiction, of the United Methodism Church, Inc. (WNCCUMC) and this Disaster Recovery Center, I am aware that the data and materials to which I have access are to be treated in a professional and confidential manner. This information will be used only in the conduct of official internal business of the office of WNVVUMC and this Disaster Recovery Center. I understand by signing this agreement that I have a legal commitment to abide by this confidentiality agreement. This agreement will remain in effect throughout any voluntary services or employment with the WNCCUMC and this Disaster Recovery Center.

UMCOR Liability Release

Please read the following and sign by using your mouse or finger (depending on your device). We also recommend that you download and print a copy for future reference.

Signature Required

I, the undersigned, agree to the terms above.

EMERGENCY CONTACT INFORMATION

1. Emergency Contact First and Last Name

Relationship To You

Primary Phone Number

Secondary Phone Number

Regularly Checked Email Address

2. Optional Second Emergency Contact Information

Relationship To You

Primary Phone Number

Secondary Phone Number

Regularly Checked Email Address

A signed waiver* by the attendee's parent/guardian will be required before you can download your QR code which indicates your registration is confirmed. A link to obtain waivers for all registrants will be shown on the confirmation page you will receive by email.

*as well as check payments

Running Total

$0.00

Total

$0.00

REGISTRATION OPTIONS

About The Attendee

Attendee Medical Insurance Information

PHOTO/MEDIA RELEASE

Confidentiality Agreement

UMCOR Liability Release

EMERGENCY CONTACT INFORMATION

BILLING INFORMATION