Life Defenders Training
Registration Form - This event is open to (rising) high school & college students only. When you have submitted this form please pay the applicable registration fee here: www.ichooselife.org/ldtraining
Student First Name *
Your answer
Student Last Name *
Your answer
Address *
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City, State Zip *
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Student Cell Phone # (Leave blank if student does not have a cell phone.)
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Student Email Address *
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Student Date of Birth *
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Sex *
Course Levels Previously Completed at Life Defenders *
Preferred Breakout Sessions - pick 2
T-Shirt Size (Adult Sizes) *
Preferred Roommate (Please choose only 1)
Your answer
School/Group *
Your answer
Grade 2019-2020 School Year *
Home Church
Your answer
Referring Friend
Your answer
Emergency Contact Name & Phone Number *
Your answer
Physician Name & Phone Number *
Your answer
Medical Insurance Provider & Policy Number *
Your answer
Allergies
Your answer
Dietary Restrictions
Medications
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Photo Release - allows Allen County Right to Life to use photos taken during the event to be used for marketing. *
Parent Email Address *
Your answer
Parent "Signature" - By signing, I acknowledge that I am the parent or legal guardian of the above student and that I give him/her permission to attend the Life Defenders Training on the campus of the University of St Francis. I have read and understand the description of this event, and I grant permission for emergency medical treatment on the recommendation of two medical doctors. I release Allen County Right to Life & Three Rivers Educational Trust Fund and all other sponsors and staff from any liability resulting from illness or injury. *
Your answer
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