Young Ladies Journey May 30 – june 6 | Big Sandy, TX Registration 1Personal Info2Evaluation Questions3Medical Information and Consent4Agreements This field is hidden when viewing the formToday's Date MM slash DD slash YYYY Start Your RegistrationRegistration Type(Required)Price includes program registration ($375) and room and board ($250). Taxes and fees are included.RegularJourney AlumniAlumni Registration Discount $0.00 Early Registration Discount $0.00 Total Personal InfoEmail(Required) Journey Updates Please subscribe me to the Journey updates email list! Secondary EmailThis is a cc email. For parents or an individual that will be involved with travel. PrefixMr., Mrs., etc.Name(Required) First Last Gender(Required)MaleFemaleDate of Birth(Required) MM slash DD slash YYYY Billing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone(Required)Cell PhoneUpload PicTrouble? Send to [email protected].Max. file size: 128 MB. Parents' Full Names(Required)Parents' Email(Required) Parents' Home Phone(Required)Parents' Home AddressIf different from your own.How did you hear about Journey to the Heart?(Required) Evaluation for the JourneyJourney to the Heart is about relationship - your relationship with Christ. One of the main aspects of a healthy and growing relationship is communication. A key ingredient of communication is asking questions! So, the purpose of the following questions is to help you evaluate where your relationship with God is at. Remember, these questions are primarily for you, so do your best to give an objective and honest answer.Are you a Christian?(Required) Yes No Unsure Tell us a little about how you became a Christian.(Required)What does being a Christian mean to you?(Required)Where would you say your relationship with God is at?(Required) I talk with Him, but I don't really feel like He talks back We're really close, we talk a lot, and He tells me things from His Word that are amazing We're pretty good, some days are better than others, but we're getting closer to each other We're really not on talking terms, I kind of feel as if He isn't very happy with me right now I would love to be close to Him, but honestly, I don't really even know where to start I don't care to talk to Him at all Are you excited about where you’re at in your Christian walk? Or not really? Explain…(Required)Is there something specific you’d like to get out of the Journey? Write your own thoughts or check one of the boxes:(Required) A closer walk with God Fellowship with like-minded people Direction for my life How do you feel about coming on this Journey?(Required) Really excited!! A little nervous Not 100% thrilled Medical History and Release FormDietary Restrictions:(Required)Basic substitute items may be available Gluten Free Dairy Free None of the Above Food Allergies/Sensitivities (if any, please explain below):Medication Allergies (if known, please explain below):Medical Conditions(Required) Measles Chicken Pox Polio Meningitis Stroke Seizures Eye Problems Chronic ear infections Special dental problems Asthma Pneumonia Tuberculosis Hypertension (high blood pressure) Heart Problems Hepatitis Thyroid Problems Diabetes Surgeries Heart-related illness Traumatic injuries STDs Appendectomy None of the Above Current Medications (if any):Other medical conditions staff should be aware of (please explain below):Blood Type:(Required) A + A - B + B - AB + AB - O + O - Not Sure Additional Comments:Medical Release(Required) I am 18 or older and I hereby request and authorize the leadership of the Institute in Basic Life Principles to provide or to make reasonable arrangements for any emergency medical care that may become necessary while I am participating in the Journey to the Heart. I am the parent or legal guardian of this registrant and I hereby request and authorize the leadership of the Institute in Basic Life Principles to provide or to make reasonable arrangements for any emergency medical care that may become necessary for this registrant while they are participating in the Journey to the Heart program. Electronics Agreement(Required)We want to help you get the most out of your time on Journey as possible. You spend a lot of time and money to come here, so we want to help you avoid those distractions that are so hard to ignore today, namely phones and other captivating electronics. During the week, your leader will be the “keeper-of-the-electronics.” Be ready to give your cell phone to your leader after you arrive, along with any MP3 players, laptops, iPods, etc. We will make it possible for you to call your parents and check in during the week. I have read and agree to this Terms Agreement(Required)In the rare circumstance that it would be better for the person or for the team, we reserve the right to separate someone from their team, or to send them home at their own expense and without a refund. I have read and agree to this Picture Agreement(Required)I grant to Journey to the Heart and/or IBLP, its representatives and employees the right to take photographs of me and my property in connection with the functions and activities of or related to a Journey. I authorize Journey to the Heart and/or IBLP, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Journey to the Heart and/or IBLP may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and agree to the above I also grant to Journey to the Heart and/or IBLP, its assigns and transferees to copyright, use, and publish any photographs or videos that I give to them in print and/or electronically. I agree that Journey to the Heart and/or IBLP may use such photographs or video with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.(Required)I also grant to Journey to the Heart and/or IBLP, its assigns and transferees to copyright, use, and publish any photographs or videos that I give to them in print and/or electronically. I agree that Journey to the Heart and/or IBLP may use such photographs or video with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and agree to the above Consent and Release Form(Required) I have read and agree to the Consent and Release Form Comments, Special Needs, or RequestsCoupon Total(Cancellations will be refunded with a $50 processing fee.) Credit CardIf you would like to pay by check or other, please contact us at [email protected] or call 903-636-9484. Cardholder Name Card Details
