Believe 2020
Please fill this form out for each child planning to attend CIY Believe on March 6th-7th.
Student Name *
Your answer
Grade *
Student Cell Phone (If Applicable)
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent/Guardian Email Address *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Relationship to Child *
Your answer
Student's Allergies *
Your answer
Permission Statement
By typing your full name below you are hereby giving your permission that the child in your care named above attend CIY BELIEVE with the Mt. Pulaski Christian Church Student Ministry on March 6th-7th. By signing below, you accept that the price of this trips is $75. The price includes registration, transportation, lodging, and all meals while in the care of Mt. Pulaski Christian Church. In order to have completed registration through us you will need to pay the full $75 by 2/20/20. If you for any reason need to make other scheduling arrangements to make sure your child can attend Believe, please contact Nate Dyer @ (217) 671-7237.
Parent/Guardian Electronic Signature (Please Type Your Full Name) *
Your answer
Submit
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