Madness & Mayhem Registration Form June 4-7 2019 6-9 pm
Asbury's Student Ministry Registration Form Grades 6-12
Email address *
Student's First Name *
Your answer
Student's Last Name *
Your answer
Street Address *
Please enter student's street address
Your answer
City *
Please enter student's city
Your answer
State and Zip Code *
Please enter the two letter abbreviation and zip code
Your answer
Student's Phone Number *
including Area Code
Your answer
Parent/Guardian Phone Number *
Phone number where information can be communicated for the student (including Area Code)
Your answer
Secondary Emergency Phone Number *
Phone number where information can be communicated for the student (including Area Code)
Your answer
Student's Allergies *
Your answer
Student's Home Church *
Your answer
Student's School and Grade in the Fall *
Your answer
Student Email *
Email where notices may be sent about upcoming events and information or none
Your answer
Parent/Guardian Email *
Email where notices may be sent about upcoming events and information or none
Your answer
What Night will Student be Attending? *
Required
Consent to Photograph/Video and Publish *
By registering I give permission for Asbury Church to take photographs and videos of the minor listed above and to use them in publications including but not limited to web pages, bulletin boards, flyers, and newsletters, understanding that the minor will not be identified by name.
Required
Parent Release Agreement *
By checking the box below, on behalf of this student, I, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in Madness and Mayhem and agrees to hold harmless and indemnify Asbury UMC any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
Required
A copy of your responses will be emailed to the address you provided.
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