BSR 2018 REGISTRATION FORM
HEAVEN | MAY 17-20 | SOUTH PADRE ISLAND, TX | $185
GENERAL INFORMATION
Last Name *
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First Name *
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Gender *
Age *
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Attendee's Grade for 2018-2019 year *
What Church Do You Attend? *
Attendees T-Shirt Size *
Do you need a ride? *
Are you willing to drive? If yes, how many can you take? *
Your answer
Do you plan to come up late or leave early from retreat? If yes, please give approximate time you will be arriving or leaving. *
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How do you plan to pay for retreat? (Payment due Friday, May 11th) *
CONTACT INFORMATION
Attendee's Cell Phone Number *
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Attendee's Email *
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Emergency Contact Name & Number (e.g. John Smith, (875) 525-2954) *
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MEDICAL INFORMATION AND CONSENT
Please list any medical conditions, and any other medical details including any prescriptions that we need to be aware of (Write NA if this doesn't apply): *
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Do you have any medically necessary dietary restrictions (i.e. food allergies)? (Write NA if this doesn't apply): *
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By typing my full name below, I hereby acknowledge I am 18 or older and authorize my participation in the activities of Bereans Retreat. In consideration of Believers Fellowship involved providing these activities. I, do hereby release all participating churches, their agents, pastors and members of their Board of Elders from all claims and causes of action by reason of any injury which may be sustained as a result of these church activities, whether on or off the church premises or on the way to or from these activities. I hereby give my permission to the physician, nurse, or dentist selected by participating churches to secure medical or dental aid as required for illness or injury under a physician’s orders, including transportation to and from the necessary facilities. As a participant, I understand that Believers Fellowship is not obligated to carry any insurance to cover those medical and/or dental expenses. If such insurance is carried, coverage will be provided only for expenses in excess of the limits of the participant’s insurance. I understand that my personal insurance is my primary coverage. Please type your name below to agree to the above statement and to indicate that you are giving your permission to participate in Bereans Winter Retreat as hosted by Believers Fellowship. *
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