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4738 Walnut Grove Road Memphis, TN 38117Get Directions

Sunday Worship

Morning Services: 8:30 & 11 a.m.

Evening Service: 6 p.m. (most Sundays)

Sunday School: 9:45-10:45 a.m.

Event Registration

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Buffalo Retreat on Friday, November 12, 2021 @ 4:00 PM

0.00
We currently can not process American Express credit cards.
1100.00 
1160.00 
10.00 
*Attendee's Age:
*Attendee's Birthdate:
Attendee's School:
Attendee's Cell:
Father's Name:
Father's Cell:
Father's Email:
Mother's Name:
Mother's Cell:
Mother's Email:
Two names of other students your child would like to room with? :
*Shirt Size:
I understand that in making this $160 payment, that if my student drops from this trip within three weeks of departure, I won't receive a refund in any amount. I also understand that if my student drops from this trip, and that I inform the youth staff at IPC before the three-week no refund deadline, that they will work to fill the spot. I understand that if they can fill the spot before the three-week no refund deadline, that I will only receive a refund of $60, and that I will forfeit $100, and that if the youth staff can't fill the spot before the three-week no refund deadline, that I won't receive a refund of any amount. 
*Emergency Contact Full Name :
*Emergency Contact 1 Phone Number:
*Is there any medical/health information we need to know while your child is with us (allergies, medication, physical limitations, etc)? All medication will be collected at check-in. Please explain:
*
I hereby give my permission for my child (or myself) to participate in the Junior High Buffalo Retreat, Nov. 12-14, 2021 @ Victory Ranch, in Bolivar, TN. I certify that my child is (or I am) healthy and capable of participating, or I have communicated any medical conditions of which Independent Presbyterian Church (“IPC”) should be aware that may hinder my child’s (or my) participation. I understand that it is solely my responsibility to determine if there is any medical reason that my child (or I) should not participate. In consideration for IPC allowing my child (or me) to participate, I hereby, on behalf of myself and on behalf of my minor child, release, discharge, waive my right to sue, and agree to indemnify and hold harmless IPC, its directors, officers, staff, employees, volunteers, agents, and third party contractors, from any and all legal claims, liabilities, losses, expenses and demands of any nature whatsoever, including those related to personal injury, sickness, harm, death, or property damages suffered by my child or me as a result of, or arising in any way out of, my child’s (or my) participation. Furthermore, I acknowledge that there are risks involved in participating, and I hereby, on behalf of my minor child, assume all risk of personal injury, sickness, death, damage and expense arising out of or related to my child’s (or my) participation. I hereby authorize IPC and its staff, employees, volunteers, agents, and third party contractors to provide necessary transportation, food, and lodging for my child’s (or my) participation. In the event of a medical emergency, I understand that IPC will make reasonable efforts to contact me or my child’s (or my) emergency contacts, however: (1) I authorize IPC and its staff, employees, or volunteers to administer first aid or CPR to my child (or me), if they think it is necessary; (2) I authorize IPC and its staff, employees, or volunteers to administer appropriate medication to my child (or myself) if they deem it necessary, except for any medications I have listed below, to call for emergency treatment, if necessary, to transport my child (or myself) to a medical treatment facility, and to consent, if I or the emergency contacts cannot be reached, to xrays, medical or dental examination, diagnosis, treatment, or hospital care, including emergency surgery, as advised by the treating physician, surgeon, or dentist; and (3) I authorize IPC and its staff, employees or volunteers to disclose any relevant medical information about my child (or me) as necessary for his/her (or my) treatment. I understand that I will be solely responsible for any medical, hospital or related charges, which may be incurred, on behalf of my child (or myself)  in connection with any injury, illness or other medical condition suffered by him/her (or me) during these trips or activities. Upon request, I will reimburse IPC for any charges paid by them on my child’s (or my) behalf. I also authorize IPC, its staff, employees, and volunteers to photograph or digitally record images of my child (or me) and to record my child’s (or my) voice during his/ her (or my) participation and I authorize IPC to use such photos, images or recordings for any purpose relating to the IPC youth ministry. I waive any and all privacy or intellectual property rights I or my child may have with respect to any such photos, images, or recordings, and release IPC and its directors, officers, staff, employees, volunteers, agents, and third party contractors, from any and all legal claims, demands, or causes of action, of any nature whatsoever, relating to photos, images, or recordings taken of my child (or me) pursuant to this authorization. 
*Signature Agreeing to the Release of All Claims and Consent to Medical Treatment:
*Date of Signature :
Health Insurance Company:
Health Insurance Group #:
Health Insurance Member #:
I understand that after submitting this registration and making this payment, that I will need to print off, fill out, and sign the Victory Ranch Minor Release, which is available on the IPC IDK webpage, and that I will turn it in to the IPC Youth Staff no later than Oct. 27. 
*I understand that there will be a video that at least one parent and the student attending must watch prior to the trip departure that covers important information as well as expectations for students while on this trip.