Mother/Daughter Encounter Registration Form

Check in time on Friday is between 5:30 PM - 6:00 PM in Big Rapids on March 12-14, 2027.

You are welcome to come anytime after 3:00 PM. The encounter will end Sunday before 11:00 AM.

Cost of the event is $199.00 due at time of registering. This includes the price of the mother and one daughter.

Participant Details

Mother's First Name

Mother's Last Name

Mother's Birthday

Month

Day

Year

Mother's Email

Mother's Phone

Mother's Food Allergies

Mother's Shirt Size

Daughter's First Name

Daughter's Last Name

Daughter's Birthday

Daughter's Food Allergies

Daughter's Shirt Size (Adult Sizes)

Multi-line address

Country/Region

Address

City

Zip / Postal code

What is the name of your home church?

How did you hear about us? (If friend or church, please indicate the name)

Prayer Requests

Release & Waiver

By submitting this agreement, the undersigned desires to participate in various retreats programs, events, and activities operated by Theroadmap Inc. and The Broken Wheel Ranch Ministries.

The undersigned acknowledges that participation may incur personal injury or bodily damage and that The Road Map Inc and Broken Wheel Ranch Ministries will not allow participation without releasing and holding harmless The Road.

Further the undersigned agrees to hereby release and forever discharge The Road Map Inc their officers, directors, employees, agent, volunteers, and property owners of The Broken Wheel Ranch Ministries from all actions, claims injuries damages, cost, or expenses related to any activity in which the undersigned participates.

As the parent/legal guardian, I have read and agree to the Liability Waiver and Release for myself and my minor daughter.

Mother/Adult Participant

By Signing below, I agree to the terms of the Liability Waiver and Release on my own behalf.

Full Legal Name

Participant Signature

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Parent/Legal Guardian on Behalf of Minor Daughter

I certify that I am the father/legal guardian of my daughter listed on this form. By signing below, I agree to the release and waiver agreement on behalf of my minor child and myself.

Full Legal Name of Participant under the age of 18

Parent/Legal Guardian Full Name

Parent/Legal Guardian Signature

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Emergency Contact Name

Relationship To Emergency Contact

Emergency Contact Phone Number

Emergency Contact Email

Payment Options

Mother/Daughter Payment Options

Mother/Daughter Registration$199