CityLights Urban Project

1. First Name Required Question

2. Last Name Required Question

3. Preferred Name

4. When will you be attending CityLights? Required Question

5. Gender

	Male
	Female

6. Date of Birth Required Question

7. Ethnic Heritage

8. School Attending Required Question

9. InterVarsity chapter information
(leave this blank if this does not apply to you)

Chapter Name
InterVarsity Staff Worker

10. Year in school

11. Major

12. Career you will probably pursue

13. Current mailing address Required Question

Address1
Address2
City
State
Zip

14. Phone Number Required Question

Home Number
Cell Number

15. Permanent Address Required Question

Address1
Address2
City
State
Zip

16. Phone number at your permanent address Required Question

17. Emergency Contact Information
Required Question

Name
Relationship
Phone Number

18. Medical Insurance Information Required Question

Company
Policy #

19. Date of your last tetanus shot Required Question

20. Have you attended CityLights Before? Required Question

	Yes
	No

21. If you are returning to CityLights for your 2nd or more time what year(s) did you previously attend?

22. Would you consider yourself highly skilled (able to lead a team) at any of the following: (check all that apply)

23. I consider myself "fluent" in the following languages:

24. Although not "fluent", I can understand:

25. How are you traveling to St. Louis? Required Question

	Drive
	Fly
	Other

26. Do you have any allergies or medical conditions staff should be aware of to avoid problems and to assure proper emergency action? If so please describe them below: Required Question

27. Please list the names of any medications you are currently taking or have taken in past month:

28. Please list any food restrictions that staff should be aware of to avoid problems: Required Question

INDIVIDUAL RELEASE AGREEMENT
By entering your name in the text box below I agree to the following statements of release:

1. In consideration for being accepted and allowed to participate in this conference/project and activities associated with its program and location, I personally assume responsibility for my actions, and release InterVarsity Christian Fellowship/USA® (hereafter InterVarsity®), its Trustees, employees and agents from loss, injury or damage to myself or my property; provided that nothing contained herein shall excuse InterVarsity, its Trustees, employees or agents from responsibility to act with reasonable care for the safety of myself or my property.

2. I give permission to InterVarsity to be photographed, recorded, and/or video taped and to allow this material to be used for publicity.

3. I give permission to InterVarsity to obtain medical assistance in the event of an emergency. This permission will include the administration of medicines, surgical treatment, X-ray examination or hospitalization as might be ordered by a licensed medical doctor. I release and discharge InterVarsity, its trustees, employees, and agents from any liability for any first aid rendered or treatment performed pursuant to this consent.

4. I understand that InterVarsity has a hostage policy that states that InterVarsity should not yield to demands, including the payment of ransom or other extortion, issued through the use of hostage taking or extortion.

5. Any claim or dispute arising from or related to this release shall be settled by mediation and, if
necessary, legally binding arbitration in accordance with the rules of a mutually agreed upon alternative dispute resolution service. Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction.
These methods shall be the sole remedy for any controversy or claim arising out of this release and I expressly waive my right to file a lawsuit in any civil court against InterVarsity for such dispute, except to enforce an arbitration decision. I certify that I am competent to sign this Release, and have done so voluntarily.

(If you are under 18 and not living away from parent/guardian by entering your name into the text box below you state that your parent/guardian consent to your participation in this activity and agree to the terms of the above release.

Required Question

Type your name here if you agree to the above release: