Here s how you sign up. To secure your spot we ll need: $50 non-refundable deposit The CIY Liability Form FCC Medical and Liability Forms

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1 First Christian Church - Monticello, IL High School Conference CIY Move is an annual 5 day conference held for high schoolers - and no one is better at reaching high schoolers than Christ in Youth. Their intentionality and quality is unmatched. This trip is for incoming Freshmen to outgoing Seniors. Located on college campuses across the nation, Move provides a program for 25,000 high school students every summer. Students are challenged through intense, interactive worship, dynamic preaching, small group study, and community building. Each year our students come back changed in their faith and community. This is the event that every student comes back talking about for months; easily the highlight of our year. When students get away from the everyday routines and distractions of life, God speaks. So the primary reason we attend is to hear what God has to say to us. The second reason is that our community is built and deepened. Being in a van for hours with people and sharing almost every waking moment with people creates long-lasting bonds. It s just that simple. Here are some details: This year we re heading Knoxville, TN and will be staying on the campus of Johnson University. We will leave the church on Sunday, June 7th at 1:00pm and will being staying the night in Lexington, KY. We ll then head from KY the rest of way to Johnson University on June 8th. We plan to return on June 12th around 6:00pm. The cost for the conference is $300. This includes your transportation to and from the event, housing, the conference itself, and food for the week. Because our trip is further than usual, you will need extra cash for six fast food meals, as well as for anything extra you d want to buy (t-shirts, etc.). In this economy, I realize $300 is a lot of money, and budgets are tight enough as it is. Please check out the fundraising sheet attached to this letter! Here s how you sign up. To secure your spot we ll need: $50 non-refundable deposit The CIY Liability Form FCC Medical and Liability Forms Deadline to sign-up is April 5, The remaining money ($250) is due no later than Sunday, May 17th. Please do not hesitate to contact Tim with any questions: tim@fccmonticello.org or Check out ciy.com/move for info. Space is limited this year, sign up early!

2 Medical Consent Form-First Christian Church *EVERYONE MUST FILL OUT THIS FORM! - CIY MOVE 2015 Name: Birthdate: Gender: Grade: / Sponsor Address: Phone: ( ) City: State: Zip: Emergency Information Parent/Guardian: Phone: ( ) Cell Phone ( ) Alternate Contact: Phone: ( ) Cell Phone ( ) If attempts to reach the above contacts are unsuccessful, please try to reach our pediatrician or physician Physician s Name: Office Phone: ( Dentist s Name: Office Phone: ( ) ) Health History Allergies Asthma Insect Stings Drug Allergies Hay Fever Other Major Problems Diabetes Nervous Disorder Emotional Handicap Physical Handicap Cardiac Epilepsy Seizure Disorder Chronic Asthma Mental Handicap Other If you have circled any of the above, please give specific details: Activity Restrictions: Date of Last Tetanus Shot: Insurance Information Should your child require medical treatment while participating in a church sponsored event, your own family medical insurance is the primary carrier and will be billed first. First Christian Church s insurance will be the secondary carrier for submission of the remaining medical costs. This does not guarantee that all remaining costs will be covered by First Christian Church s carrier. Policyholder: Name of Insurance Carrier: Policy Number: (I)/(We), the undersigned, parent(s) of, a minor, do hereby authorize the adult sponsors of First Christian Church, as agent(s) for the undersigned, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, which is deemed advisable by, and is required to be rendered under the general or special supervision of, any physician or surgeon, and whether such diagnosis or treatment is rendered at the office of said physician or at a hospital or other health care facility. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of the aforesaid agent(s) to consent to any and all such diagnosis, treatment, or hospital care which may be determined by a physician or surgeon, as aforesaid, to be advisable in the exercise of his/her best judgment. Print Name of Parent or Guardian: Signature of Parent or Guardian: Date:

3 LIABILITY RELEASE AGREEMENT FIRST CHRISTIAN CHURCH 1699 N. State St. Monticello, IL The undersigned (herein the Individual ) wishes to participate in the following activity: CIY Move Conference Knoxville, TN June 7th - 12th, 2015 (herein the Activity ) sponsored by First Christian Church, a nonprofit religious corporation (herein the Church ) The Church and the undersigned agree that this activity poses a risk which includes, but is not limited to, the following specific risks Bus/Van transportation, horseplay, recreational activity as well as similar and dissimilar risks (herein the Risks ). For and in consideration of the Church allowing the Individual to participate in the Activity, and other good and valuable consideration the receipt and sufficiency of which are hereby acknowledged, the undersigned, for himself or herself, assigns, heirs, and the next of kin (herein the Releasors ), release, waive, discharge, and covenant to not hold liable the Church and its officers, employees, and agents (herein the Releasees ), from all liability to the Releasors, on account of injury to the Individual or death to the Individual or injury to the property of Individual caused by the negligence of Releasors while the Individual is participating in the Activity. The undersigned is fully aware of the Risks and other hazards inherently in the Activity and is voluntarily participating in the Activity, and voluntarily assumes the Risks and all other risks of loss, damage or injury that may be sustained by the Individual while participating in the Activity. The undersigned warrants that he or she (and parents or guardians) has fully read and understands this Liability Release Agreement and voluntarily signs the same, and that no oral representations, statements, or inducements apart from the foregoing written agreement have been made to the undersigned. CAUTION: READ BEFORE SIGNING Print Name of Parent or Guardian: Signature of Parent or Guardian: Date:

4 Christ In Youth Discipline, Liability & Medical Release Form Make a copy for yourself and bring the ORIGINAL to registration Event you will be attending: SuperStart! Believe MIX Move Engage Wilderness Please check which one best describes your attendance: Sponsor Student Youth/Children s Minister Participant Name Male Female Address City State Zip Participant Home Phone H.S. Graduation Year Church You are Attending with (missions trip n/a) City/State Group Leader s Name (missions trip n/a) Health Insurance Company Policy Number Known Allergies and Reactions Medications Currently Taking Parents/Legal Guardians Name (with whom you live) Emergency Contact Info of Parent/Legal Guardian: Cell Phone Parent(s) Person to notify if parent/legal guardian cannot be reached: Name Relationship Phone I, the participant or for those under 18 the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in this Christ In Youth Program. The individual identified on this form understands that all participants are required to abide by the Program rules and be directly responsible to the Christ In Youth Program Director. The Christ In Youth Program Director assumes responsibility for discipline at the Program and, if necessary, may, because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for returning the participant home. Further, I hereby release, forever discharge and agree to hold harmless a) Christ In Youth and its directors, officers, employees, Program Directors, agents and all other persons or entities acting on their behalf (the Covered Parties ) and b) the lessor/owner of properties on which the Programs are held, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the participant, the undersigned, and/or any member of the participant s family by reason of participating in any activities associated with Christ In Youth Programs whether or not such claims, actions, demands, liability, costs or expenses are caused by the negligence or omission of any of the Covered Parties. It is my intention to, and I do hereby surrender and waive any rights to sue or exercise any legal right to seek damages from the Covered Parties from their failure to use reasonable care in any way. Further, I do authorize the minister or sponsor of the Program, or any Christ In Youth staff member to take the participant to a doctor or hospital and I hereby authorize medical treatment, including by not limited to emergency surgery or medical treatment, and I hereby assume financial responsibility for all expenses incurred for such treatment and, if necessary, all expenses to return the participant home. Further, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of the participation in this Christ In Youth Program. I hereby release and agree to hold harmless and indemnify the Covered Parties, for any liability and/or expense sustained as the result of negligent, willful or intentional acts of the participant, including damages to the Program facility and/or keys not returned at the time of group checkout. I agree to pay for keys not returned at time of group checkout or damage done to any Program facility or Christ In Youth property by the participant. For valuable consideration received, I hereby irrevocably grant to Christ In Youth, Inc. the worldwide, royalty-free, right to use the participant s name, voice, likeness, and image in all forms and media, and in all manners for any lawful purposes, commercial or noncommercial. I understand that my participation makes me eligible to receive educational information and updates regarding ministry successes and opportunities. I acknowledge this agreement is intended to be as broad and inclusive as permitted by the laws of the state of Missouri and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further agree this agreement will be governed by and construed in accordance with the laws of the State of Missouri without giving effect to the principles of conflict of law and the courts within Missouri will be the only courts of competent jurisdiction. I hereby irrevocably submit to the personal jurisdiction of the courts of Jasper County, Missouri. I hereby certify that I have carefully read the foregoing and acknowledge that I understand and agree to all of the above terms and conditions. I am aware that by signing this agreement I assume all risks and waive and release certain substantial rights that I may have or possess against Christ In Youth or any of the covered parties. Signature of Participant Named Above (If under 18 parent or legal guardian must sign) Printed Name of Parent/Legal Guardian Date Signature of the Parent/Legal Guardian Christ In Youth -- PO Box B -- Joplin, MO

5 2015 Summer Trip Fundraising Summer trips with the Student Ministry are expensive. And in today s economy, coming up with the extra money to send your child on these trips can seem next to impossible. So we want to help you with a creative and fun way to help your child earn the money for their trips. This is where Krispy Kreme Donuts come in. Their fundraising program is really leaps and bounds beyond any other fundraiser out there. You earn money for each item you sell. For example, as a church, we are able to purchase the donuts for $3.25/dozen. You will sell them for $7/dozen. You profit $3.75 for your trip AND your customers are still able to purchase the donuts cheaper than they would be able to purchase them at retail. Here s the cool part. Each person will be earning money for themselves. If you want to sell 80 boxes of donuts to pay for your entire trip, you are more than able to do so! This is an individual effort. You will be selling the following products: 1 Dozen Orignal Glazed Donuts - $7.00 Certificate for 1 Dozen Glazed Donuts - $7.00 Partnership BOGO Cards - $12.00 Krispy Kreme Coffee - $10.00 ($3.25 profit) ($3.25 profit) ($6.00 profit) ($4.00 profit) As you can see, there is a ton of potential to raise the funds for your trip fairly quick. So if you re on board and ready to go, here s what you need to do. Grab the order sheet attached to this packet and start selling. Collect the money from your customers at the point of sale. Have any checks made out to First Christian Church. You ll need to have your full order and money to me by May 10th, I will be placing our church order the following Monday so we can have their orders to them by May 16th. Let your customers know that you will have their donuts (and other items) ready for them on May 16th, Then, you ll come pick up your order at the church at around 10am that Saturday. At this point, it ll be up to you to distribute your orders. Then the funds will then be credited directly to your account! It s my hope that this will provide you a way to help cover some, if not all, of the cost of these trips. The life change and fun that happens on these trips is well worth your effort! For His Kingdom, Tim Stanek Student Minister tim@fccmonticello.org

6 ORDER FORM Hello, I m from I m selling Krispy Kreme products to raise money for Check the product you are selling: Fresh Krispy Kreme doughnuts for a price of Krispy Kreme Fundraising Certificates for a price of per dozen. each. Krispy Kreme BOGO Fundraising Cards for a price of 12 oz. Bags of Krispy Kreme Signature Coffee for a price of each. (available in House Blend [HB], Dark Roast [DR] and Decaf [DC]) CUSTOMER NAME AND ADDRESS each. HB # OF 12 OZ. BAGS OF SIGNATURE COFFEE DR DC AMOUNT COLLECTED ITEM # KKDC TOTALS

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