Thank you for registering for CHALLENGE Basic 2017. 

This form is for those who did not complete it during registration.

Your name *
Your name
Must be over 18
Home phone number *
Home phone number
Cell phone number *
Cell phone number
Home address *
Home address
Attendee name *
Attendee name
Gender *
Birth date
Birth date
Have you, or do you now have any of the following medical conditions: *
Physician's Name: *
Physician's Name:
Physician's Phone: *
Physician's Phone:
Date of last Tetanus Shot: *
Date of last Tetanus Shot:
(adult sizes only)
What is your experience with firearms? *
In consideration for being permitted to participate in Challenge activities on private property in Pine Mountain, GA, I do hereby agree to waive, indemnify, and hold harmless the property owner and/or the Timothy Group, its agents, servants, and employees from any and all claims, demands, causes of action, liability, judgments, costs and attorney’s fees arising out of, claimed on account of, or in any manner predicated upon my trip, including any claims and actions for property damage or personal injury I receive in connection with such trips. I further agree to indemnify and hold harmless the property owner and/or the Timothy Group, its agents, servants, and employees, and waive liability for any additional claims, suits, or actions for personal injury, loss of consortium, and property damage for which my heirs, executors, administrators, agents, and each of them, may hereafter acquire against the property owner and/or the Timothy Group, its agents, servants, and employees to the extent that such claims, suits, or actions derive from injury, damage, or death that occurs in connection with my trip and participation in the Timothy Group events.
Please include church name and location.
To attend CHALLENGE, a pastor must provide you a reference. Give the name of the Pastor who will be providing you a reference.