This support ministry to  youth groups is completely volunteer with no fee charged 
for kitchen and cooking service,  inside eating and activity tables,  
inside beds and/or outside tents for sleeping, transportation, and support as agreed.
Your group leaders are responsible for programming, the organization, and the supervision of their group members. 

Print, fill out and mail this page to:
Bill & LaVerne Blickley
1312 Dunham S. E.
Grand Rapids, MI   49506
(616) 452-2683
Make sure to keep a copy for your own records.

Emergency Organizational Phone #______________ Emergency Organizational Cell Phone # ____________

Number of days for outing: ________  Dates for outing: Beginning ______________ Ending____________

Note: Plan for at least one day travel time for each 350-400 miles of travel.

Specific location/address of your planned youth group activity: ____________________________________________

Number of people in outing: ________ Number of people requesting sleeping accommodations:__________

Number of people requiring food preparation: ______ Number of meals per day: ______ Total Meals:_______
For groups of more than 16 people please check with us for special sleeping, cooking, storage, and cleanup arrangements.

Amount of deposit included : _____________ ($50. per day, $100. minimum, [up to 20 people] )
                                                          
We have read and support the personal conduct rules.  Yes____ ,  Please send us a copy.____

Is your organization located in, and/or are the group members from a lower income neighborhood? Yes ___,  No ___

We (our youth group)  will provide an insurance certificate showing that each of our group members is insured with liability coverage by our insurance company, and  showing William & LaVerne Blickley and Wherever God Wills non-profit youth group support service as an additional insured on the certificate for this event.  Check these certificate examples:    Certificate#1,   Certificate#2  Certificate#3

NOTE:    We are using all the recommended operating procedures recommended by The Church Mutual Insurance Company (which insures many Protestant churches) and Michigan's Catholic Conference Insurance Company .

We (our church/organization youth group) will provide a  signed liability release, waiver & indemnity agreement for each person on this outing from the parents/guardians of each minor and from each adult participant.  
We understand that our group leaders are responsible for programming, the organization, and the supervision of our group.  
We (our church/organization youth group) will provide the insurance certificate at least 10 days before we are scheduled to leave and the signed liability waivers for each member of the group at least one day before our departure from Grand Rapids.

Youth group Leaders Signature: __________________________________ Date_________________________

Donations given to help us pay the general expenses for this ministry are tax deductible.