2020 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 *
Student Last Name *
Address *
City, State Zip *
Student Cell Phone # (Leave blank if student does not have a cell phone.)
Student Email Address *
Student Date of Birth *
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Sex *
Course Levels Previously Completed at Life Defenders *
Preferred Breakout Sessions - Pick 1
T-Shirt Size (Adult Sizes) *
Preferred Roommate (Please choose only 1)
School/Group *
Grade during the 2020-2021 School Year *
Home Church
Referring Friend
Emergency Contact Name & Phone Number *
Physician Name & Phone Number *
Medical Insurance Provider & Policy Number *
Allergies
Dietary Restrictions
Clear selection
Medications
Photo Release - allows Right to Life of Northeast Indiana to use photos taken during the event to be used for marketing. *
Parent Email Address *
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 Right to Life of Northeast Indiana & Three Rivers Educational Trust Fund and all other sponsors and staff from any liability resulting from illness or injury. *
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