Eugene Youth Rally 2020
ER 2020 Registration Form (To be completed NO LATER than February 9th, 2020).

The all-inclusive cost for ER 2020 is $40.00. Please mail checks to Eugene Church of Christ, 2424 Norkenzie Rd, Eugene OR. 97408. BE SURE TO WRITE FULL STUDENT NAME IN MEMO LINE. Please be aware that it is our philosophy that no child be unable to attend due to financial need. Donors have generously provided sponsorships for those in need of financial assistance. Simply select the options for financial assistance in this form.

***PLEASE READ EACH SECTION CAREFULLY***
Name (Last, First) *
Your answer
Sex *
Grade *
Age *
MM
/
DD
/
YYYY
T-Shirt Size *
Church affiliation: What church do you regularly attend? (Type “none” if you don’t attend a church congregation) *
Your answer
Parent/Guardian Name (Staff-type in your name) *
Your answer
Street Address *
Your answer
City, State, Zip Code *
Your answer
Emergency Contact (Provide name AND phone number) *
Your answer
Medical Information *
Please provide information on any medical conditions as well as medications and dosage (If none, type “none.”)
Your answer
Insurance *
Please provide your insurance company, policy number, & name of policy holder for use in the unlikely event of an emergency.
Your answer
Payment *
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