Please provide your contact information. Required information is notated with an asterisk. All other information is optional but helpful.

Do you have a home church?

Do you have any special dietary requirements or Food Allergies?

Do you have any medication regimens that we need to be aware of?

Are there any other special provisions that you need in order to stay and enjoy this Keryx weekend?

I do hereby consent to and agree that Keryx Ministries, its employees, or agents have the right to take photographs, videos, or audio recordings during the weekend event and to use these in any and all media, now or hereafter known, exclusively for the purpose of advertising, fundraising, and recruiting for the Keryx ministries. I further acknowledge that my name and identity may be revealed therein or by descriptive text or commentary and I consent to its use in these ways.

I do hereby release to Keryx Ministries, its agents, and employees all rights to exhibit this work in print and electronic form publicly or privately and to market and sell copies for the sole purposes stated within this agreement. I waive any rights, claims, or interest I may have to control the use of my identity or likeness in whatever media used.

I understand that there will be no financial or other remuneration for use of my likeness or name. I also understand that Keryx Ministries is not responsible for any expense or liability incurred as a result of my participation in the procurement of the photos, videos, or audio recordings during the weekend including, but not limited to, loss of wages or medical expenses due to any sickness or injury incurred as a result.

I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

Do you agree to these terms?