High School ICYC 2018
Cost is $150 through November 1. After November 1 price will be $200 - includes ticket, 2 nights lodging, transportation and food. We will leave the church @ 4pm Friday November 16 and will return around Sunday November 1 around 4pm. The event is held at Anderson University in Anderson, IN.

If finances are an issue, we have scholarships available.

Student's First Name *
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Student's Last Name *
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Gender
Date of Birth *
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Student's Cell Phone *
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Student Email *
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Father's Name *
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Father's Contact Number *
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Father's Email *
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Mother's Name *
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Mother's Contact Number *
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Mother's Email *
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Family Doctor and Contact Number *
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Health Plan Information *
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Policy # *
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Known Allergies
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If not a member of SFCC, which church do you regularly attend? *
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T Shirt Size *
Roommate request
If applicable
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We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by First Christian Church of Scottsburg. *
By typing your name you are giving consent.
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Date Signed by Parent or Guardian *
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