Teen Extreme Rally/Lock-in
Event Timing: November 8-9, 2019
Event Address: Address: 190 N Elmwood Ave, Lindsay, CA 93247
Contact us at (559) 667-1076 /
Cost: Early Registration $45/Person August 30th - October 18th, 2019
Late Registration: $55/Person October 19th -November 8th, 2019 (at the Door)
Church and Leader
Emergency Contact (First and last name)
Relation to participant?
Emergency Contact Number (Home or Cell)
I Understand that I must Sign and Turn in BOTH the PCG Youth and McDermont Field House release of liability wavers (These are available at
). I understand NO ONE will be granted admission to this event without both liability waivers.
I will be paying via:
Credit card (You will be redirected to payment screen)
Check or cash mailed in *Make payable to* "Ccpcg youth " (Please send check upon completion of this form and ignore payment screen)
At the door
Payment will be Made by my Church
Today I will be paying:
The $25 Pre-Registration per person to hold each spot. (The rest will be due prior to event)
I will pay the entire amount now
My Church will make my payment (Make sure your church is listed in this form)
Central California District, PCG Inc. 2019 TEEN EXTREME LOCK-IN MEDICAL RELEASE FORM
I understand and acknowledge that if I proceed to register online and to sign the waiver electronically, that, under the Electronic Transactions Act, such electronic registration and electronically signed Waiver document will be valid and enforced in the same manner as a hand-signed document that exists in physical form and that a record or signature may not be denied legal effect or enforceability under law solely because it is in electronic form.
Central California District, PCG Inc. 2019 TEEN EXTREME LOCK-IN MEDICAL RELEASE FORM. Continued
MEDICAL RELEASE (to be filled out by Parent/Guardian)
I HEREBY AUTHORIZE THE CENTRAL CAL YOUTH MIN. AND/OR ITS REPRESENTATIVE, AS AGENT FOR MYSELF TO PROCURE MEDICAL, HOSPITAL OR DENTAL CARE FOR MY CHILD NAMED ON THIS FORM, IN THE EVENT OF INJURY OR ILLNESS WHILE THE CHILDIS IN THE CARE OF THE ABOVE NAMED, I UNDERSTAND THAT I AM FINANCIALLY
RESPONSIBLE FOR ANY CARE PROCURED. IT IS UNDERSTOOD THAT THIS AUTHORIZATION IS GIVEN IN ADVANCE OF ANY SPECIFIC DIAGNOSIS, TREATMENT, OR HOSPITAL CARE BEING REQUIRED. BUT IS GIVEN TO PROVED AUTHORITY ON THE PART OF MY AGENT TO CONSENT TO SUCH MEDICAL CARE, SHOULD IT BECOME NECESSARY. I ALSO AUTHORIZE DESIGNATED MEDICAL PROFESSIONALS TO DISPENSE OVER THE COUNTER MEDICATIONS AS NEEDED TO THE STUDENT LISTED ABOVE. I HEREBY IRREVOCABLY CONSENT TO AND AUTHORIZE THE UNRESTRICTED USE AND REPRODUCTION BY YOU OR ANYONE AUTHORIZED BY YOU, OF ANY AND ALL PHOTOGRAPHS AND/OR VIDEO IMAGES WHICH YOU HAVE TAKEN OF THE STUDENT LISTED ABOVE, FOR USE WITHIN THE SCOPE OF THE CENTRAL CALIFORNIA YOUTH MINISTRIES, PENTECOSTAL CHURCH OF GOD, INC.
After having read, or have had read to me, I agree to abide by the rules and regulations of the event and to waive any and all claims against the District Organization, The Pentecostal Church of God, or any of its District Board or its representatives, because of any injury or other damage that may be incurred to me or my property in connection with,
or incident to, the Pentecostal Church of God. I also give my permission for any pictures taken maybe used for Central Cal Youth Ministries.
I understand, agree and acknowledge the previous paragraphs
No, I will download and turn in a physical copy of the "Medical Release Form"
If you are a chaperone please provide the following information. If you are not a chaperone proceed to SUBMIT FORM.
Child Abuse Training & Background Check (This must be completed in order to chaperone at any PCG event). Have you completed your church’s child abuse program and background check?
Pastors Printed Name and Phone Number
A copy of your responses will be emailed to the address you provided.
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