The Hero in YOU!

First EVER Weekend Getaway

Who: What: Sponsored by Region 5 of Illinois South Conference. Any high school student is welcome! A weekend full of friends, fellowship and growth. Truly a weekend to get away from the everyday stresses of every High School kid

When: 8pm.Friday April 12th-Sunday April 14th (Conclusion of Worship) Where: Salem United Church of Christ, 1116 W. North St. Alhambra, IL 62001 How: Food will be provided. Cost of the weekend will be $30 per youth. Each group attending will need to provide 1 chaperone for every 5 kids attending. Forms must be completed and filled out before youth and chaperone are admitted.

For questions call or Email: Nick Atkins-Harris (812) 589-1918 or [email protected]

What is a weekend getaway?

A Weekend Getaway is a great chance for you and your youth group to meet, fellowship, and get to know some of the other youth in the area and in the Illinois South Conference. It is also a weekend for you to get away from all of the stresses of life, and refill your spiritual tank at an affordable price and its close to home!

Who, What, When, Where, How

Weekend Getaway Hero in YOU!

Presented by the Region 5 planning team Weekend long retreat or Weekend Getaway Starts at 8pm April 12th and ends after church on Sunday April 14th Salem UCC Alhambra, Il Cost is $30 if registered before April 1. $40 if registered after that date 1 Chaperone (adult 21 or over) required for every 5 youth attending from your group

Salem
United Church of Christ Alhambra, IL 8pm April 12th 14th

Chance to do a mission project in the community Opportunity to be in a different place for the weekend Small group talks Vespers and games Make connections Free time!

Retreat Emphasis

There was an idea to bring together a group of remarkable people so when we needed them, they could fight the battles that we never could- Nick Fury

At this retreat youth will talk about how each of us holds amazing power that God has given us. How we use this power is up to us. Youth will have the opportunity to break into small groups and dive into conversation about whatactuallymakesahero,andhowtheythemselvesare heroes in their own way. Youth will also have plenty of time to meet other youth who attend; play group games (including the ultimate super hero challenge); experience down time spent however the youths choose; and help outthecommunitywithamissionproject! We will eat together; worship together; and fellowship together for a weekend that is meant to bring the youth in the area together; take home and share with their churches what they learn throughout the weekend; and buildonwhatisalreadyinplace. We hope that this becomes something for the youth to look forward to every year. We would like to move the location around to all of the churches in the area and give everyoneanopportunitytohostaGetawayWeekend.

The Hero in YOU! John 1 4:4 Weekend Getaway

April 12th -14th
Friday Night 8:00-9:00 9:00-9:45 10:00 10:15-11:15 1:00 Saturday 8:00-8:30 9:00 Arrival & gathering Introductions, rules Opening Vespers Small Groups 1 Lights Out

and opening game

12:00 12:30 1:30

6:00 7:00

12:00 Sunday 8:00-9:00 8:30

Breakfast Story and Ropes Discussion Worship Prep Lunch Open time Work projects Discussion Worship Prep Dinner Group games Discussion Worship Set-up Worship Closing

Arrival and gathering Check-in with Nick forms Read and sign event covenant Set-up sleeping space Return to Parish hall for gathering and snacks Make a Cape to represent you. (Include name, where you are from. This will be your nametag for the weekend.

11:00-11:30 11:30

Cabin Clean-Up Breakfast Discussion wrap-up Evaluations Worship Have a safe trip home!

Weekend Getaway 2013

Sponsored by Region 5 and the Illinois South Conference of the United Church of Christ

FINAL REGISTRATION INSTRUCTIONS

The following forms, completed for each youth and adult chaperone, must accompany the Group Registration Form and final payment:
For Youth 1. Youth & Adult RegistrationHealth Information form, with SIGNATURES and with copies of insurance cards or a note that insurance is unavailable 2. Permission & Authorization form with SIGNATURES For Adults 1. Youth & Adult RegistrationHealth Information form, with SIGNATURES and with copies of insurance cards or a note that insurance is unavailable 2. Permission & Authorization form with SIGNATURES 3. State of Illinois, Department of Children and Family Services Authorization for Background Check form, with signature Make copies of all forms and provide a copy for chaperones to carry during travel and keep with them during the event-just in case of an emergency.

DEADLINE THURSDAY, April 1st, 2013

Weekend Getaway 2013

Church/Town

Youth & Adult Registration--Health Information (Please Print or Type

in Ink)
Name of Attendee (First) Attendee Phone #1 Circle: Day / Evening / Cell Date of Birth City Custodial Parent / Guardian (if youth) Phone #1 - Circle One: Day / Evening / Cell Food Allergies / Special Dietary Needs (please be specific) Limitations or Restrictions on Activities Current Medical Conditions, including Allergies (Describe any medical conditions that might be affected by strenuous or general event activities, for example any muscle or skeletal issues, allergies to animals, etc.). (Last) Attendee Phone #2 Circle: Day / Evening / Cell ________________________________________ Age as of Jan1, 20123 State Grade Zip Code Gender __
Mailing Address__________________________________________________________________________________

E-mail__________________________________________________________________________________________

Phone #2 - Circle One: Day / Evening / Cell

Date of last Tetanus Shot (month/year)

Approximate Weight (for medication administration)

Prescription / Over-the-Counter Medications to be taken during event (list times and dosages) Any additional health information church advisors/event leaders should be aware of (surgery or serious injuries, chronic or recurring illness/medical condition, psychiatric counseling or indications, recent traumas, life changes etc.) ADDITIONAL EMERGENCY CONTACTS (if parent/guardian listed above CANNOT be reached): NAME Relationship NAME Relationship Name of Physician Name of Dentist/Orthodontist Medical/Hospital Insurance: Carrier I.D. / Policy / Group # Dental Insurance: Carrier I.D. / Policy / Group # Special Insurance Instructions
** ATTACH A COPY OF THE FRONT & BACK OF HEALTH INSURANCE CARD TO THIS FORM **

Day Phone ( Evening Phone ( Day Phone ( Evening Phone ( Phone ( Phone (

) ) ) ) ) )

PERMISSION & AUTHORIZATIONS Signatures Required

Name of Youth or Adult Attendee Last First Age (if under 21) MI

Illinois South Conference United Church of Christ Region 5

Event Name: Weekend Getaway 2013

The individual named above has my permission to attend the event listed above.

Event Date: April 12th-14th , 2013

PERMISSION FOR PARTICIPATION IN EVENT & EVENT ACTIVITIES:

The individual named above has my permission to participate in transportation to, from and during this event provided or arranged by the attendees church, event coordinators or Illinois South Conference staff members. I / We (attendee and parent if attendee is a youth participant) understand and support policies prohibiting the use or possession of weapons, tobacco products (if youth participant), alcoholic beverages and illegal drugs or controlled substances. We recognize that all attendees must follow safety guidelines and refrain from harmful behavior. I/We understand that if an attendee is unable to live within these guidelines and those outlined in the Covenant, he/she may be sent home without a refund of the program fee. There are challenges inherent with participation in any event activity, including but not limited to archery, boating, challenge course, games, hiking, horseback riding, swimming, wagon rides and work projects. I understand that these challenges, which contribute to the unique character and desirability of the activities, pose the possibility of severe injury, illness or death. I further understand that many event activities may take place in an outdoor environment. For this and other reasons, I understand the challenges often cannot be eliminated, altered, or controlled. I give permission for myself and/or my child to participate in all event activities, including but not limited to those described above. I acknowledge and assume the risks involved in these activities, and for any damage, illness, injury, or death resulting from such risks, for myself or my child. There are no physical, emotional or mental problems or limitations associated with my childs or my participation in event activities, except as disclosed by me in writing to the Illinois South Conference. I have read and understand the above, and agree to the terms of this waiver. Signature of Adult Attendee or Custodial Parent / Guardian Date

To the best of my knowledge, the health information on this form is correct and accurately reflects the current health status of the attendee named above. I hereby give permission to the advisor from the attendees church, event coordinators and Illinois South Conference staff members to provide, seek, and consent to first aid, routine health care, administration of prescribed medications, emergency treatment and transportation for me or my child, as may be deemed necessary. I also give permission to medical personnel, authorized by the advisor from the attendees church, event coordinators and Illinois South Conference staff members to order x-rays, routine tests and proper treatment related to the health of the attendee for both routine care and, in emergency situations, to hospitalize, order injections, anesthesia, or surgery for me or my child. I understand the information on this form will be shared on a need to know basis. I give permission to photocopy this form. It is my intention that the advisor from the attendees church be treated as acting in loco parentis if the person named herein is a minor. I agree to the release of any records necessary for treatment, Attach a copy of your insurance card. referral, billing, or insurance purposes.
Signature of Adult Attendee or Custodial Parent / Guardian

PERMISSION FOR FIRST AID, EMERGENCY TREATMENT AND TRANSPORTATION:

Date

The Illinois South Conference utilizes a variety of media, such as brochures, newsletters, media productions such as PowerPoint presentations, videos, Facebook, and our websites to interpret and promote our ministry and programs. Recognizing the value of these interpretive materials, I hereby grant the Illinois South Conference of the United Church of Christ, or their designated agents, permission to use images of myself or my child for interpretive or promotional efforts. Signature of Adult Attendee or Custodial Parent / Guardian

PHOTO RELEASE:

Date

Region 5 of The Illinois South Conference

Weekend Getaway 2013 GROUP ALLOCATION/REGISTRATION FORM

DEADLINE April 1st, 2013
Church & City Contact Day Phone ( E-Mail Address: Please PRINT the information indicated for each person attending. List YOUTH Participants on the FRONT side and ADULT Chaperones on the BACK side. ) Phone ( Position Evening Phone ( ) )

NAME
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11 12. 13. 14. 15. 16.

Fee Paid

Grade in T-Shirt Gender School Size

Reg & Health

($15) Permis. Youth Horse & Auth Covenant Ride

TOTAL NUMBER OF YOUTH PARTICIPANTS

CONTINUED ON BACK

Please PRINT the information indicated for each person attending. List YOUTH Participants on the FRONT side and ADULT Chaperones on the BACK side.
Fee Paid T-Shirt Reg & Gender Size Health DCFS DCFS ($15) Perm Adult Bckgrnd Discl Report Horse & Auth Covenant Auth Statement Recd Ride

NAME
1. 2. 3. 4. 5.

Male Female Chaperone (age 21+) Coverage:

If you do not have the appropriate chaperone coverage (1 male adult per 1-7 male youth, 1 female adult per 1-7 female youth), please explain coverage plans on a separate sheet of paper.

CONFIRMED SPACE ALLOCATION

---------------------------------------------------------------------------------------------------------------------------TOTAL NUMBER of YOUTH & ADULTS:
Received on or before April 1st, 2013

@ $30 = @ $50 =

TOTAL NUMBER of YOUTH & ADULTS:

Received after April 1st, 2013

GRAND TOTAL DUE = __________

Make Check Payable to: Salem United Church of Christ MAIL TOTAL DUE AND ALL REQUIRED FORMS TO: Salem United Church of Christ- 1117 W.North St. Alhambra, IL 62001

Illinois South Conference Adult Volunteer Disclosure Form

This form needs to be completed by all adult advisers and volunteers attending Weekend Getaway 2013. Please return with Group Allocation/Registration form.
Name: _______________________________________________________________________________ Address: _____________________________________________________________________________ Street City State Zip Phone: _______________________________ E-Mail Address: __________________________________ Church Name/Town: ____________________________ Pastors Name: __________________________ 1. Have you ever been found guilty, or pled guilty or no contest to a criminal charge alleging actual or attempted sexual harassment, exploitation, misconduct, physical abuse, or child abuse? Yes No If yes, give an explanation. _____________________________________ ____________________________________________________________________________ 2. Has a formal complaint been made against you in a civil, ecclesiastical, educational or employment setting alleging actual or attempted sexual discrimination, harassment, exploitation, misconduct, physical abuse, or child abuse? Yes No If yes, give an explanation. _____________________________________ ____________________________________________________________________________ 3. Is there any fact or circumstance involving you or your background that would call into question your being entrusted with responsibilities in any childrens program of the Illinois South Conference? Yes No If yes, give an explanation. _____________________________________ ____________________________________________________________________________

Release and Authorization

I acknowledge that the information provided in this disclosure is true and complete. I authorize the Illinois South Conference and/or their agents to investigate all statements contained in it. I also authorize all persons and entities to respond to inquiries concerning me, to supply verification of the information provided in this application and to comment regarding my background and character. I hereby release all such individuals and entities from all liability and responsibility arising from their doing so. I waive any right that I may have to inspect records, references, or information collected or acquired in connection with this application. Signature: ________________________________________________ Date: _______________________

What to bring
Clothes o One set of work clothes for our mission project these should be clothes you wont mind getting dirty. o All other clothes for the weekend can be comfortable, we will be attending church on Sunday morning, if you would like to bring dressier clothes you can but you do not have to. All clothing will be welcomed. Shoes o Please bring a set of closed toed shoes for running around and work projects. Toiletries o We will have one chance to shower throughout the weekend. Please bring the necessary toiletries in order to make this happen. Shampoo, deodorant, towels, etc. Bedding o Air mattress o Pillows o Blankets Cameras, iphones, ipods o Please bring your chargers for all devices but we will encourage you to be disconnected from home. You will be able to use music devices at night during lights out.

Weekend Getaway

We are also asking that you bring a yard of your favorite color or pattern of fabric. We will be creating a super hero cape for your nametag for the weekend. You are also encouraged to bring/wear anything super hero related!