Registration: Awakening Mentor Genius Registration

Awakening Mentor Genius May 12-15 Registration

Thursday May 12 4:00pm to Sunday, May 15, 2022, 3:00pm

Location: Camp Arrowhead - Zirconia, North Carolina

Participant Information

First Name

Last Name

Email Address

Cell Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Will the participant be 18 or older at the start of the weekend?

Yes, over 18 as of May 12, 2022

No, under 18 as of May 12, 2022

Parent's Information

Parent's First Name

Parent's Last Name

Parent's Email

Parent's Phone Number

Confidential Medical Questionnaire

If you become ill or injured during ROPAW you authorize us to share this information with medical personnel. Otherwise, all information will be kept strictly confidential.

Will the participant taking any medication (prescription or nonprescription) that will be required during the weekend?

Yes

No

Please List Medications, how much (mg), how often needed, and current side effects

Emergency Contact Full Name & Relationship

Emergency Contact Phone Number

Do you have health insurance

Yes

No

Insurance Company

Policy Number

Insurance Co. Phone Number

Do you have any medical or psychological condition that would affect your participation in the weekend?

Yes

No

If yes, please explain:

In case of medical emergency please list specific instructions:

Please list food allergies and/or food sensitivities and label as such.

Consent Disclaimer

I consent that Journeymen may photograph and videotape parts of the upcoming weekend in order to promote future Journeymen events. By signing and returning this form I give my or my participants' consent to Journeymen (this is a voluntary request).

• I agree that participants may be interviewed, recorded and photographed by Journeymen or any person Journeymen mandates to that effect.

• I accept that Journeymen may or may not use participants name, image and likeness in any verbal presentation, conference, interview and written publication.

• I recognize that Journeymen shall have the exclusive rights to the materials indicated above, including copyrights and proprietary rights, and I assign to Journeymen any right in relation to the materials.

• Journeymen may not assign or transfer, in whole or in part, the rights granted by the present contract.

Consent

Release & Acknowledgement of Risks

I have read and agree to the Terms and Conditions.

My Commitment: (please check where appropriate)

I agree to arrive at Camp Arrowhead on Thursday, May 12 by 4:00pm and agree to participate until Sunday, May 15 at 3:00pm

I am aware that my acceptance to participate is subject to a background check no older than 18 months and that Journeymen must run its own background checks.

I volunteer to help clean-up the site on Sunday afternoon

Payment

Participation Fee: The $400 participant fee covers lodging and food Thursday - Sunday as well as supplies and some administration fees. Our weekends are driven by many volunteer hours. We do not want finances to be a barrier for you and will work with you to make this weekend accessible. Additionally, we ask those who can to pay it forward to help cover the costs of folks who may otherwise not be able to afford the full tuition.

Note: You will be directed to pay via PayPal when you click "Register and Pay" below.

Choose Payment Option:

Full Tuition: $400

Deposit: $100

Remaining Fee: $300

Please Contact Me To Make Payment Arrangements

Registration: Awakening Mentor Genius Registration

Awakening Mentor Genius May 12-15 Registration

Confidential Medical Questionnaire

Consent Disclaimer

Release & Acknowledgement of Risks

Payment

Rites of Passage

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