Disciple Now: Vision 2020
An awesome teen retreat starting at 6:00 pm Friday, March 13 and running until 12:30 pm Sunday, March 15, 2020 at Apollo Baptist Church.

Before completing this form, please understand:

* This form is due by Wednesday, February 19, 2020 to guarantee a spot and t-shirt for your student.

* This form is meant to be completed by the parent or legal guardian, not the student.

* You will need to submit a separate on line form for each student and worker.

* In ADDITION to this form, you will need to submit the $25.00 event cost, per student, either to Reginald Givens or to the church office.

* You will need to either drop off your student in person and sign the liability waiver on the day of the event or request a waiver in advance and have it notarized.

EVENT REGISTRATION
Fill out a separate registration form for each student and worker.
Student or Adult Worker Name *
Your answer
Student's Grade Level *
Student's T-Shirt Size *
Parent/Guardian Name *
Your answer
Parent/Guardian Phone # *
Your answer
Parent/Guardian Email *
Your answer
I prefer to be contacted via: *
MEDICAL INFORMATION
Parent/Guardian Emergency Contact Name and Phone # *
Your answer
Non Parent/Guardian Emergency Name and Phone # *
Your answer
Are our event staff authorized to approve medical treatment? *
Is the student covered by personal/family medical insurance? *
Insurance Name and Policy #
Your answer
Does your student have any food allergies? *
Your answer
Does your student have other allergies that need to be considered when staying away from home (i.e. pet dander)? If yes, please explain.
Your answer
Is there anything you wish to disclose regarding your student's health as it pertains to participating in games or being away overnight?
Your answer
Disclosures & Acknowledgements
I understand the retreat cost is $25.00 per student and is due by February 19, 2020 to guarantee a T-Shirt and I also understand all payments must be made by cash or check written to "Apollo Baptist Church." *
I understand I will need to sign the actual event waiver for my student to participate in this event and will either sign it in person at check-in or request a copy ahead of time that I will sign and have notarized. *
I am the student's parent or legal guardian and verify all the above information is accurate to the best of my knowledge. *
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