2019 Breakthrough Registration
Participant Information
First Name *
Your answer
Last Name *
Your answer
Gender *
Tee-Shirt Size (adult sizes) *
Housing *
Where will you be sleeping those 2 nights?
Participant's Cell Phone
This info is optional
Your answer
Mailing Address *
Example for format: 123 Nazarene Way Lenexa, KS 55555
Your answer
Contact Email *
This is the parent or legal guardian email address. For adult participants just use your own email address.
Your answer
Home Church? *
Health & Wellness Questions
Health Insurance Provider / Company *
Your answer
Insurance Policy Number *
Your answer
Insurance Phone Number of Company *
Your answer
List any allergies, major surgeries or other medical conditions we should be aware of:
Please do NOT hit the enter button when filling out this box.
Your answer
Emergency Contact Information
Emergency Contact Person(s) Name & Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
Participant's Health *
I, the legal guardian, will do everything I can to send my child to this event in the best health including, but not limited to; being aware of any fever, vomiting or other signs of sickness, checking them for Lice (live or eggs), and reviewing good hygiene before the attend. If I find any significant health issues for my teen, I will communicate with the event director so we can discuss options and/or whether to withhold my teen from attending (full refund provided).
Releases & Permissions
Age Category *
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