Believe 2017
Please fill this form out for each child planning to attend CIY Believe on March 3rd-4th.
Student Name *
Your answer
Grade *
Student Cell Phone (If Applicable)
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent/Guardian Email Address *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Relationship to Child *
Your answer
Student's Allergies *
Your answer
Permission Statement
By typing your full name below you are hereby giving your permission that the child in your care named above attend CIY BELIEVE with the Mt. Pulaski Christian Church Student Ministry on March 3-4 2017. You are also verifying you have an up to date Liability and Media Release Waiver on file with the church. If you have not done that you can do so by visiting www.mtpulaskicc.org/safe or if you would like to find out if you have one of these on file, please send an email to garrett@mtpulaskicc.org. By signing below, you also understand that the cost for this trip is $60 if paid before February 1, 2017 and $70 after February 1 but before February 17, 2017. The price includes registration, transportation, lodging, and all meals while in the care of Mt. Pulaski Christian Church. If you for any reason need to make other scheduling arrangements to make sure your child can attend Believe, please contact Garrett LeVault @ (217) 415-5677.
Parent/Guardian Electronic Signature (Please Type Your Full Name) *
Your answer
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