Rally Registration
February 15-17
Ages 12-18
Time: 6PM Friday - 1PM Sunday
2424 Norkenzie Rd Eugene OR, 97408
Name *
Your answer
Grade (or indicate if chaperone or staff) *
Your answer
Parent/ Guardian *
Your answer
Home Church *
Your answer
Gender *
Shirt Size *
Do you need housing? *
Housing Preferences (location or buddy)
Your answer
Payment: $35 for Attendees $15 for Chaperones (Includes: housing, meals andshirt) Make checks payable to: Eugene Church of Christ *
Required
Food Exceptions (IE: vegetarian or any food allergies)
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Emergency Contact *
Your answer
Emergency Contact Phone Number *
Your answer
Medical Information (Please list any medical conditions that might limit the attendee In activates)
Your answer
Insurance Provider *
Your answer
Policy Number *
Your answer
Medical Treatment AuthorizationAs parent or guardian authority is given to the Eugene Rally staff to place theattendee under the care of a legally qualified physician, dentist, or hospital if in the judgment of the ER staff it is considered advisable. Eugene Rally is released fromany liability in connection with the attendee. Parent/Guardian Electronic Signature and Date *
Your answer
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