AFFIRM 2019 Participant Registration

To complete your registration, we recommend that you have the following items ready:

  • Participant unit preferences - first and second choice!  View Unit Descriptions >>
  • Contact information for Home Congregation & Pastor
  • Insurance Information
  • Completed UWA Waiver (we cannot accept digital signatures; you will need to print, sign, and upload the form)  Download the form >>
  • Payment & scholarship information
  • Medication Information (including name and dose) if your child takes medication (prescription OR over the counter of any kind)
  • Your participant's signature will be required - make sure they're around when you begin the form!
  • YAYMI applications require a recommendation for your participation in this program from someone other than a pastor or parent.  You can submit that here or ask the reference to email it directly to AFFIRMSES@gmail.com.
  • YAYMI applicants should complete their own application.

Instructions:

  • All required components, including deposit, must be in place in order to process and submit your registration. 
  • All information must be sumbitted at once.  You cannot return to an incomplete form this year.  It may take aprx. 15 minutes per participant to complete this form.  
  • If your application is successfully submitted, you will receive an email confirmation. 
  • If you do not receive a confirmation, your registration did not process and you'll need to resubmit.
  • You may register up to three participants associated with the same parent/guardian.
  • The registration deadline is May 1, 2019.

If you have any questions or concerns regarding registration, please don't hesitate to contact our registrar, Emily Gantert, at AFFIRM2018@gmail.com or at 762.585.5108.  Please note that this is a volunteer position, so calls and emails are likely to be returned in the evening or on weekends and allow 1-2 days for a reply.

 

Parent/Guardian Information

PARENTS - provide the following information for the primary parent contact.

YAYMI Applicants - provide your parents' names, but please use YOUR email address so that you receive the confirmation.

*First Name
*Last Name
*Address 1
Address 2
*City
*State
*Zip
*Email
*Phone
Second Parent/Guardian First & Last Name
Second Contact Email
Second Parent/Guardian Phone Number
Emergency Contact
*Emergency Contact First & Last Name

Other than parent/guardian(s) listed above!

*ER Contact Relationship to Participant
*ER Contact Phone Number
Pastor Endorsement

We will reach out to your pastor for an endorsement for each participant you register.

*Home Congregation
*Congregation City, State
*Pastor's First and Last Name
*Pastor's Email
PARTICIPANT #1 INFORMATION
*P1 / Legal Name (First and Last)
P1 / Goes by/Preferred Name
P1 / Participant email

Please do not repeat parent email.  If they don't have an email - leave field blank.

P1 / Participant phone

Please do not repeat parent phone.  If they don't have a phone number- leave field blank.

*P1 / Gender
*P1 / Date of Birth
*P1 / Age as of June 1, 2019
*P1 / Grade Completed as of June 1, 2019
*P1 / T-shirt Size

Only adult sizes are available

*P1 / Select all previously completed units
Genesis
Missionaries
Journeys
Shepherds
Revelations
Worshiptivity
Science & Faith
Bridges
Exodus
None of the above; I'm a first time AFFIRM-er!
*P1 / 2019 First Choice Unit

Reminder: Grades shown are grade the participant should have completed in order to be eligible for that unit.  

We will do our best to honor everyone's first choice unit.  However, there are no guarantees that you will be placed in this unit.  Registration is not necessarily first-come, first-served.  Final decisions about unit choices are based on a number of factors.  Please contact our registrar if you have any questions about unit placement.

*P1 / 2019 Second Choice Unit

In the event that we cannot place you in your first choice unit, this is the unit you will be placed in.  If a second choice unit is not selected (or is the same as first choice unit), participant will be placed in another unit by the admin staff and we will not be able to move them.  Please be sure you have reviewed this with your participant.  Thank you.

*P1 / Do you play an instrument?
Yes
No
*P1 / I play...
*P1 / Do you want to participate in the AFFIRM Choir?

Rehearsals will be one hour during free time each day and the choir will perform during closing worship on Friday.

Yes
No
YAYMI / Please complete this application prayerfully and thoroughly.
*YAYMI / What gifts and talents would you bring to the Young Adult Youth Ministry Institute? Please include your Spiritual Gifts!

You can take a spiritual gift assessment at https://tinyurl.com/AffirmSG 

*YAYMI / Describe your Youth Ministry experience. What age youth do you prefer to work with and why?
*YAYMI / What attracted you to the Young Adult Youth Ministry Institute? What do you hope to gain from this experience?
*YAYMI / How will you share this experience with others after AFFIRM week?
YAYMI / Reference Upload

If you do not have your reference yet, please be sure to send it to AFFIRMSES@gmail.com ASAP.

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

DISCLOSURES

All information submitted in this section remains confidential between parents, AFFIRM administration and, as need be, AFFIRM staff.

Please submit any information that may help us to ensure this participant has a successful week at camp.  You can update this information anytime prior to camp check-in by emailing us at AFFIRMSES@gmail.com. If we feel that we are unable to appropriately accommodate these needs, we may choose to decline your application or if the determination is made upon arrival, send the participant home.

*P1 / Allergies

If there are not any allergies, write 'none'.

*P1 / Dietary Needs

If there are not any dietary needs, write 'none'.

*P1 / Physical Challenges

If there are not any physical challenges, write 'none'.

*P1 / Emotional or Behavioral Concerns

If there are not any emotional or behavioral concerns write 'none'.

*P1 / Is there anything in this participant's medical history that will assist our team in the event that they require medical care?

If there is not anything signifigant in their medical history, write 'none'.

*P1 / Is there anything else we should know to ensure this participant has a successful week at AFFIRM?

If there's nothing else we should know, write 'no'.

*P1 / Does this participant regularly take any over the counter or prescription medications?

Please note: AFFIRM medical team stocks things like Advil, tums, sudaphed, etc.  Do not send these medications with your participant 'in case'.  However, if this participant routinely takes any kind of medication, requires an epi-pen or other prescribed 'in case' meds, plan to send that medication with them and select 'yes' here to be directed to the medication form.

Yes
No

P1 / Medication Form
Follow the prompts below until you reach a confirmation notice (after pressing the blue submit button).  Then scroll down to continue your registration.
You will receive a separate confirmation email for the medication form which will include a link allowing you to update your submission at any time.

*P1 / Does this participant have insurance?
Yes
No
*P1 / Policy Holder's First and Last Name
*P1 / Insurance Company
*P1 / Insurance Company Phone Number

Usually found on the back of your card

*P1 / Policy or Group Number
*P1 / Member or Subscriber Number
P1 / Additional Information that may be helpful:
P1 / Upload a copy of your insurance card (optional)

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

*P1 / Participant's SSN

Enter without dashes, please.  If we your participant does not have insurance, we must have their social security number to expedite care in case of an emergency.  This information is not used for any other reason.  Contact our registrar if you have any questions.

WAIVERS FOR PARTICIPANT #1
*P1 / UWA Waiver

The University of West Alabama requires that we have a hard copy of their liability form.  Please complete the form and upload it here.  Need the form?  Click here >>

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

*P1 / Synod Liability Waiver In consideration of being accepted by the Southeastern Synod, ELCA for participation in youth ministry events, I (we) do for myself (ourselves) and on behalf of my child/participant do hereby release, forever discharge, and agree to forever hold harmless the Southeastern Synod, ELCA, the employees, and agents thereof, from any and all liability, claims and demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by me or my child/participant resulting from said child's participation in the synod sponsored youth events, including travel, recreation and all associated activities. Further, I (we) (and on behalf of our child/participant under 18 years of age) hereby assume all risk of said personal injury, sickness, death, damage and expenses as a result of participation as above set forth. I also understand that staff and volunteers are responsible for the administration of prescribed medication and I (we) have made private arrangements for any medication taken on a daily schedule by my child/participant. I (we) am (are) the parent(s) or legal guardian(s) of this participant, and hereby grant my (our) permission for him/her to participant fully in said youth events, and give my (our) permission to take said to a doctor or hospital, share the above medical information and authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and assume responsibility of all medical bilLs incurred by my child/participant. I(we) give permission for my child to receive over the counter medications such as Tylenol, ibuprofen, antidiarrhea medication, antibacterial ointment, throat lozenges, eye wash solution, and the like. I (we) also release the participant’s name as part of an information database for the Southeastern Synod and ELCA related entities, and grant the Southeastern Synod and ELCA unrestricted rights to use, alter, and reproduce any images(still and video) from the event, in any medium without compensation.

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature

AFFIRM Community Covenant

As a Christian Community grounded in Scripture, striving to give and receive affirmation, each member of the community will...

  • Assume Full Responsibility for Your Own Behavior by:
    • Being present for the entire event and participating in ALL activities with your Unit as well as AFFIRM Community activities.
    • Remaining within the physical boundaries of the AFFIRM community.
    • Being inside your dorm, on your hall, at evening devotion time.
    • Wearing an I.D. at all times.
    • Not bringing alcoholic beverages, drugs, cigarettes, Juul/vape pens, weapons including firearms and knives, fireworks, or other inappropriate or illegal items. There is a 100% no-smoking or vaping policy for this event!
    • Giving a cash or check deposit of $50 for your room. This deposit is refunded if your room is in good condition and key is returned.
    • Keeping your room locked at all times (AFFIRM is not responsible for lost or stolen items)?.
    • Wearing Christian community appropriate clothing & shoes at all times, unless at the pool or in your room.
    • Making no alterations to your physical appearance (ie. dying hair, piercings, etc.).
    • Refraining from use of electronic devices outside of dorm rooms or during free time. Devices should not be used during Unit time or AFFIRM Community events unless specifically allowed by unit director.  Staff will have cell phones available for emergency situations.
  • Be Respectful TO and OF Others by:
    • Being in your room, music off, quiet, and lights out at predetermined time on schedule.
    • Staying on the dorm floor/wing/room assigned unless accompanied by a staff member.
    • Taking care of property and equipment not belonging to you and reporting any damaged items to the AFFIRM staff immediately (you will be charged for damages you cause).
    • Respecting the community boundaries. This is a closed Christian Community – you may not invite outside guests or leave the campus unless approved by the Affirm Director(s).
       
  • Be Supportive of All AFFIRM Staff, Participants, and UWA Campus Personnel by:
    • Modeling our Christian beliefs through your behavior.
    • Arriving on time to scheduled events, beginning with registration on Sunday from 2:00-5:00pm all the way through pick-up on Friday at noon.  This means participants may not arrive before registration and should stay through the entire event.
    • Not switching rooms (as a matter of safety).
    • Reporting all sickness or injury to your Affirm staff and medical team and allowing all prescription and over the counter medicines to be given by the Medical staff only.  No medications shall be self-administered.

To provide clear boundaries to promote a SUCCESSFUL event, one or more of the following responses will be enacted for violations of the established rules:

  • Warning to Participant / Clarification and review of the guidelines.
  • Acknowledgement of Behavior / Fair and appropriate steps will be taken to rectify the problem within the small group or by the Unit Directors if possible.  A form will be signed & dated at this meeting. Parents will be notified.
  • Participant Sent Home / At the discretion of the Affirm Director and Unit Directors, participant to be picked up as soon as possible or sent home at parent's expense.  The participant will not be allowed to return to the AFFIRM community at any point during this event. In some cases, they may also not be allowed at future events.

Observing these guidelines will help our time together to be more effective and safe, allowing each of us to receive maximum benefit from the event.

*P1 / Participant Acknowledgement By signing below, I signify that I have read and understand these Guidelines and agree to observe them at AFFIRM 2019. Participants will be asked to re-commit to this covenant at check-in.

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature
*P1 / Parent/Guardian Acknowledgement As parent/guardian to this participant, I understand these Guidelines and agree to support my participant in abiding by them.

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature
*Do you need to register another participant?
Yes
No
PARTICIPANT #2 INFORMATION
*P2 / Legal Name (First and Last)
P2 / Goes by/Preferred Name
P2 / Participant email

Please do not repeat parent email.  If they don't have an email - leave field blank.

P2 / Participant phone

Please do not repeat parent phone.  If they don't have a phone number- leave field blank.

*P2 / Gender
*P2 / Date of Birth
*P2 / Age as of June 1, 2019
*P2 / Grade Completed as of June 1, 2019
*P2 / T-shirt Size

Only adult sizes are available

*P2 / Select all previously completed units
Genesis
Missionaries
Journeys
Shepherds
Revelations
Worshiptivity
Science & Faith
Bridges
Exodus
None of the above; I'm a first time AFFIRM-er!
*P2 / 2019 First Choice Unit

We will do our best to honor everyone's first choice unit.  However, there are no guarantees that you will be placed in this unit.  Registration is not necessarily first-come, first-served.  Final decisions about unit choices are based on a number of factors.  Please contact our registrar if you have any questions about unit placement.

*P2 / 2019 Second Choice Unit

In the event that we cannot place you in your first choice unit, this is the unit you will be placed in.  If a second choice unit is not selected (or is the same as first choice unit), participant will be placed in another unit by the admin staff and we will not be able to move them.  Please be sure you have reviewed this with your participant.  Thank you.

*P2 / Do you play an instrument?
Yes
No
*P2 / I play...
*P2 / Do you want to participate in the AFFIRM Choir?

Rehearsals will be one hour during free time each day and the choir will perform during closing worship on Friday.

Yes
No
Disclosures for Participant #2

All information submitted in this section remains confidential between parents, AFFIRM administration and, as need be, AFFIRM staff.  

Please submit any information that may help us to ensure your child has a successful week at camp, be it medical, dietary, behavioral, developmental, and/or emotional.  You can update this information anytime prior to camp check-in by emailing us at AFFIRMSES@gmail.com.  Please note: If we feel that we are unable to appropriately accommodate these needs, we may choose to decline your application or if the determination is made upon arrival, send the participant home.

*P2 / Allergies

If there are not any allergies, write 'none'.

*P2 / Dietary Needs

If there are not any dietary needs, write 'none'.

*P2 / Physical Challenges

If there are not any physical challenges, write 'none'.

*P2 / Emotional or Behavioral Concerns

If there are not any emotional or behavioral concerns write 'none'.

*P2 / Is there anything in your child's medical history that will assist our team in the even that your child requires medical care?

If there is not anything signifigant in their medical history, write 'none'.

*P2 / Is there anything else we should know to ensure your child has a successful week at AFFIRM?

If there's nothing else we should know, write 'no'.

*P2 / Does your child regularly take any over the counter or prescription medications?

Please note: AFFIRM medical team stocks things like Advil, tums, sudaphed, etc.  Do not send these medications with your camper 'in case'.  However, if this participant routinely takes any kind of medication, requires an epi-pen or other prescribed 'in case' meds, plan to send that medication with them and select 'yes' here to be directed to the medication form.

Yes
No

Follow the prompts below until you reach a confirmation notice (after pressing the blue submit button).  You will receive a separate confirmation email for the medication form which will include a link allowing you to update your submission at any time.  

*P2 / Does this participant have insurance?
Yes
No
*P2 / Policy Holder's First and Last Name
*P2 / Insurance Company
*P2 / Insurance Company Phone Number

Usually found on the back of your card

*P2 / Policy Number
*P2 / Group Number
*P2 / Member Number
P2 / Additional Information that may be helpful:
P2 / Upload a copy of your insurance card (optional)

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

*P2 / Participant's SSN

Enter without dashes, please.  If we your participant does not have insurance, we must have their social security number to expedite care in case of an emergency.  This information is not used for any other reason.  Contact our registrar if you have any questions.

Waivers for Participant #2
*P2 / UWA Waiver

The University of West Alabama requires that we have a hard copy of their liability form.  Please complete the form and upload it here.

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

*P2 / Synod Liability Waiver In consideration of being accepted by the Southeasterrn Synod, ELCA for participantion in youth ministry events, I (we) do for myself (ourselves) and on behalf of my child/participant do hereby release, forever discharge, and agree to forever hold harmless the Southeastern Synod, ELCA, the employees, and agents thereof, from any and all liability, claims and demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by me or my child/participant resulting from said child's participation in the synod sponsored youth events, including travel, recreation and all associated activites. Further, I (we) (and on behalf of our child/participant under 18 years of age) hereby assume all risk of said personal injury, sickness, death, damage and expenses as a result of participation as above set forth. I also understand that staff and volunteers are responsible for the administration of presscribed medication and I (we) have made private arrangements for any medication taken on a daily schedule by my child/participant. I (we) am (are) the parent(s) or legal guardian(s) of this participant, and hereby grant my (our) permission for him/her to participant fully in said youth events, and give my (our) permission to take said to a doctor or hospital, share the anove medical information and authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and assume responsibility of all medical bils incurred by my child/participant. I(we) give permission for my child to receive over the counter medications such as Tylenol, ibuprofen, antidiarrheal medication, antirbacterial ointment, throat lozenges, eye wash solution, and the like. I (we) also release the participant’s name as part of an information database for the Southeastern Synod and ELCA related entities, and grant the Southeastern Synod and ELCA unrestricted rights to use, alter, and reproduce any images(still and video) from the event, in any medium without compensation.

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature

P2 /

AFFIRM Community Covenant

As a Christian Community grounded in Scripture, striving to give and receive affirmation, each member of the community will...

  • Assume Full Responsibility for Your Own Behavior by:
    • Being present for the entire event and participating in ALL activities with your Unit as well as AFFIRM Community activities.
    • Remaining within the physical boundaries of the AFFIRM community.
    • Being inside your dorm, on your hall, at evening devotion time.
    • Wearing an I.D. at all times.
    • Not bringing alcoholic beverages, drugs, cigarettes, Juul/vape pens, weapons including firearms and knives, fireworks, or other inappropriate or illegal items. There is a 100% no-smoking or vaping policy for this event!
    • Giving a cash or check deposit of $50 for your room. This deposit is refunded if your room is in good condition and key is returned.
    • Keeping your room locked at all times (AFFIRM is not responsible for lost or stolen items)?.
    • Wearing Christian community appropriate clothing & shoes at all times, unless at the pool or in your room.
    • Making no alterations to your physical appearance (ie. dying hair, piercings, etc.).
    • Refraining from use of electronic devices outside of dorm rooms or during free time. Devices should not be used during Unit time or AFFIRM Community events unless specifically allowed by unit director.  Staff will have cell phones available for emergency situations.
  • Be Respectful TO and OF Others by:
    • Being in your room, music off, quiet, and lights out at predetermined time on schedule.
    • Staying on the dorm floor/wing/room assigned unless accompanied by a staff member.
    • Taking care of property and equipment not belonging to you and reporting any damaged items to the AFFIRM staff immediately (you will be charged for damages you cause).
    • Respecting the community boundaries. This is a closed Christian Community – you may not invite outside guests or leave the campus unless approved by the Affirm Director(s).
       
  • Be Supportive of All AFFIRM Staff, Participants, and UWA Campus Personnel by:
    • Modeling our Christian beliefs through your behavior.
    • Arriving on time to scheduled events, beginning with registration on Sunday from 2:00-5:00pm all the way through pick-up on Friday at noon.  This means participants may not arrive before registration and should stay through the entire event.
    • Not switching rooms (as a matter of safety).
    • Reporting all sickness or injury to your Affirm staff and medical team and allowing all prescription and over the counter medicines to be given by the Medical staff only.  No medications shall be self-administered.

To provide clear boundaries to promote a SUCCESSFUL event, one or more of the following responses will be enacted for violations of the established rules:

  • Warning to Participant / Clarification and review of the guidelines.
  • Acknowledgement of Behavior / Fair and appropriate steps will be taken to rectify the problem within the small group or by the Unit Directors if possible.  A form will be signed & dated at this meeting. Parents will be notified.
  • Participant Sent Home / At the discretion of the Affirm Director and Unit Directors, participant to be picked up as soon as possible or sent home at parent's expense.  The participant will not be allowed to return to the AFFIRM community at any point during this event. In some cases, they may also not be allowed at future events.

Observing these guidelines will help our time together to be more effective and safe, allowing each of us to receive maximum benefit from the event.

*P2 / Participant Acknowledgement By signing below, I signify that I have read and understand these Guidelines and agree to observe them at AFFIRM 2019. Participants will be asked to re-commit to this covenant at check-in.

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature
*P2 / Parent/Guardian Acknowledgement As parent/guardian to this participant, I understand these Guidelines and agree to support my participant in abiding by them.

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature
*Do you need to register a third participant?
Yes
No
PARTICIPANT #3 INFORMATION
*P3 / Legal Name (First and Last)
P3 / Goes by/Preferred Name
P3 / Participant email

Please do not repeat parent email.  If they don't have an email - leave field blank.

P3 / Participant phone

Please do not repeat parent phone.  If they don't have a phone number- leave field blank.

*P3 / Gender
*P3 / Date of Birth
*P3 / Age as of June 1, 2019
*P3 / Grade Completed as of June 1, 2019
*P3 / T-shirt Size

Only adult sizes are available

*P3 / Select all previously completed units
Genesis
Missionaries
Journeys
Shepherds
Revelations
Worshiptivity
Science & Faith
Bridges
Exodus
None of the above; I'm a first time AFFIRM-er!
*P3 / 2019 First Choice Unit

We will do our best to honor everyone's first choice unit.  However, there are no guarantees that you will be placed in this unit.  Registration is not necessarily first-come, first-served.  Final decisions about unit choices are based on a number of factors.  Please contact our registrar if you have any questions about unit placement.

*P3 / 2019 Second Choice Unit

In the event that we cannot place you in your first choice unit, this is the unit you will be placed in.  If a second choice unit is not selected (or is the same as first choice unit), participant will be placed in another unit by the admin staff and we will not be able to move them.  Please be sure you have reviewed this with your participant.  Thank you.

*P3 / Do you play an instrument?
Yes
No
*P3 / I play...
*P3 / Do you want to participate in the AFFIRM Choir?

Rehearsals will be one hour during free time each day and the choir will perform during closing worship on Friday.

Yes
No
Disclosures for Participant #3

All information submitted in this section remains confidential between parents, AFFIRM administration and, as need be, AFFIRM staff.  

Please submit any information that may help us to ensure your child has a successful week at camp, be it medical, dietary, behavioral, developmental, and/or emotional.  You can update this information anytime prior to camp check-in by emailing us at AFFIRMSES@gmail.com.  Please note: If we feel that we are unable to appropriately accommodate these needs, we may choose to decline your application or if the determination is made upon arrival, send the participant home.

*P3 / Allergies

If there are not any allergies, write 'none'.

*P3 / Dietary Needs

If there are not any dietary needs, write 'none'.

*P3 / Physical Challenges

If there are not any physical challenges, write 'none'.

*P3 / Emotional or Behavioral Concerns

If there are not any emotional or behavioral concerns write 'none'.

*P3 / Is there anything in your child's medical history that will assist our team in the even that your child requires medical care?

If there is not anything signifigant in their medical history, write 'none'.

*P3 / Is there anything else we should know to ensure your child has a successful week at AFFIRM?

If there's nothing else we should know, write 'no'.

*P3 / Does your child regularly take any over the counter or prescription medications?

AFFIRM medical team stocks things like Advil, tums, sudaphed, etc.  Do not send these medications with your camper 'in case'.  However, if your camper routinely takes any kind of medication, requires an epi-pen or other prescribed 'in case' meds, plan to send that medication with them and select 'yes' here to be directed to the medication form.

Yes
No

Please follow the prompts below until you reach a confirmation notice (after pressing the blue submit button).  You will receive a separate confirmation email for the medication form which will include a link allowing you to update your submission at any time.  

*P3 / Does this participant have insurance?
Yes
No
*P3 / Policy Holder's First and Last Name
*P3 / Insurance Company
*P3 / Insurance Company Phone Number

Usually found on the back of your card

*P3 / Policy Number
*P3 / Group Number
*P3 / Member Number
P3 / Additional Information that may be helpful:
P3 / Upload a copy of your insurance card (optional)

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

*P3 / Participant's SSN

Enter without dashes.  If we your participant does not have insurance, we must have their social security number to expedite care in case of an emergency.  This information is not used for any other reason.  Contact our registrar if you have any questions.

Waivers for Participant #3
*P3 / UWA Waiver

The University of West Alabama requires that we have a hard copy of their liability form.  Please complete the form and upload it here.

Attach file pdf, doc(x), xls(x), jpg/gif/png, ppt - up to 25 MB

*P3 / Synod Liability Waiver In consideration of being accepted by the Southeasterrn Synod, ELCA for participantion in youth ministry events, I (we) do for myself (ourselves) and on behalf of my child/participant do hereby release, forever discharge, and agree to forever hold harmless the Southeastern Synod, ELCA, the employees, and agents thereof, from any and all liability, claims and demands for personal injury, sickness and death, as well as property damage and expenses of any nature whatsoever which may be incurred by me or my child/participant resulting from said child's participation in the synod sponsored youth events, including travel, recreation and all associated activites. Further, I (we) (and on behalf of our child/participant under 18 years of age) hereby assume all risk of said personal injury, sickness, death, damage and expenses as a result of participation as above set forth. I also understand that staff and volunteers are responsible for the administration of presscribed medication and I (we) have made private arrangements for any medication taken on a daily schedule by my child/participant. I (we) am (are) the parent(s) or legal guardian(s) of this participant, and hereby grant my (our) permission for him/her to participant fully in said youth events, and give my (our) permission to take said to a doctor or hospital, share the anove medical information and authorize medical treatment, including, but not limited to emergency surgery or medical treatment, and assume responsibility of all medical bils incurred by my child/participant. I(we) give permission for my child to receive over the counter medications such as Tylenol, ibuprofen, antidiarrheal medication, antirbacterial ointment, throat lozenges, eye wash solution, and the like. I (we) also release the participant’s name as part of an information database for the Southeastern Synod and ELCA related entities, and grant the Southeastern Synod and ELCA unrestricted rights to use, alter, and reproduce any images(still and video) from the event, in any medium without compensation.

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P3 / AFFIRM Community Covenant

As a Christian Community grounded in Scripture, striving to give and receive affirmation, each member of the community will...

  • Assume Full Responsibility for Your Own Behavior by:
    • Being present for the entire event and participating in ALL activities with your Unit as well as AFFIRM Community activities.
    • Remaining within the physical boundaries of the AFFIRM community.
    • Being inside your dorm, on your hall, at evening devotion time.
    • Wearing an I.D. at all times.
    • Not bringing alcoholic beverages, drugs, cigarettes, Juul/vape pens, weapons including firearms and knives, fireworks, or other inappropriate or illegal items. There is a 100% no-smoking or vaping policy for this event!
    • Giving a cash or check deposit of $50 for your room. This deposit is refunded if your room is in good condition and key is returned.
    • Keeping your room locked at all times (AFFIRM is not responsible for lost or stolen items)?.
    • Wearing Christian community appropriate clothing & shoes at all times, unless at the pool or in your room.
    • Making no alterations to your physical appearance (ie. dying hair, piercings, etc.).
    • Refraining from use of electronic devices outside of dorm rooms or during free time. Devices should not be used during Unit time or AFFIRM Community events unless specifically allowed by unit director.  Staff will have cell phones available for emergency situations.
  • Be Respectful TO and OF Others by:
    • Being in your room, music off, quiet, and lights out at predetermined time on schedule.
    • Staying on the dorm floor/wing/room assigned unless accompanied by a staff member.
    • Taking care of property and equipment not belonging to you and reporting any damaged items to the AFFIRM staff immediately (you will be charged for damages you cause).
    • Respecting the community boundaries. This is a closed Christian Community – you may not invite outside guests or leave the campus unless approved by the Affirm Director(s).
       
  • Be Supportive of All AFFIRM Staff, Participants, and UWA Campus Personnel by:
    • Modeling our Christian beliefs through your behavior.
    • Arriving on time to scheduled events, beginning with registration on Sunday from 2:00-5:00pm all the way through pick-up on Friday at noon.  This means participants may not arrive before registration and should stay through the entire event.
    • Not switching rooms (as a matter of safety).
    • Reporting all sickness or injury to your Affirm staff and medical team and allowing all prescription and over the counter medicines to be given by the Medical staff only.  No medications shall be self-administered.

To provide clear boundaries to promote a SUCCESSFUL event, one or more of the following responses will be enacted for violations of the established rules:

  • Warning to Participant / Clarification and review of the guidelines.
  • Acknowledgement of Behavior / Fair and appropriate steps will be taken to rectify the problem within the small group or by the Unit Directors if possible.  A form will be signed & dated at this meeting. Parents will be notified.
  • Participant Sent Home / At the discretion of the Affirm Director and Unit Directors, participant to be picked up as soon as possible or sent home at parent's expense.  The participant will not be allowed to return to the AFFIRM community at any point during this event. In some cases, they may also not be allowed at future events.

Observing these guidelines will help our time together to be more effective and safe, allowing each of us to receive maximum benefit from the event.

*P3 / Participant Acknowledgement By signing below, I signify that I have read and understand these Guidelines and agree to observe them at AFFIRM 2018. Participants will be asked to re-commit to this covenant at check-in.

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*P3 / Parent/Guardian Acknowledgement As parent/guardian to this participant, I understand these Guidelines and agree to support my participant in abiding by them.

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Payments & Scholarships
I'd like to apply for a Synod Scholarship

AFFIRM Synod Scholarships are available to any participant who has registered for AFFIRM.  First priority will be given to those with financial needs, especially those whose participantion are dependent on receiving this scholarship.  Considerations will also be made based on additional costs to attend (ie. travel), diversity, familiy size and first-time participants.

All applications must be completed in full and signed by participant and parent/guardian.  Application & Registration for Scholarship Applicants must be received by April 1.  Scholarships will be awarded by April 15 and an award letter will be sent to you and your pastor.

Synod Scholarship Form

I will be receiving financial support (other than Synod Scholarship)

ie) from your church or grandparent

*Please list the name of the person/organization who may be submitting payment for this participant

This will help us to efficiently and appropriately apply payments.  Thank you for your help!

*How many participants you are registering? ($425)

This will calculate your total amount due.

Only number values are allowed
*How will you be paying today?

A $200 deposit per participant is required to complete registration.  Registration is not complete until we receive the deposit.  If you or your church is sending a check, please keep this in mind.

Checks should be made out to
ELCA SOUTHEASTERN SYNOD and sent to AFFIRM PO Box 400 Decatur, GA 30031.

Check / See instructions above
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