CIY MOVE 2017
Please fill this out for each child planning to attend CIY MOVE. If you have any questions, please contact Garrett LeVault @ (217)415-5677 or garrett@mtpulaskicc.org
Student Name
Your answer
Student Phone Number (If Applicable)
Your answer
Send/Receive Text Messages?
Grade
The grade the student will be entering in the fall of 2017.
Student Mailing Address
Your answer
Parent(s)/Guardian(s) Name(s)
Your answer
Parent(s)/Guardian(s) Phone Number(s)
Your answer
Parent/Guardian Email Address
Your answer
Emergency Contact Name
Your answer
Emergency Contact Relationship to Child
Your answer
Emergency Contact Phone Number
Your answer
Permission Statement
By selecting YES and typing your FULL NAME below, you are hereby giving your permission that the child in your care named above attend CIY MOVE in Warrensburg, Missouri with the Mount Pulaski Christian Church Student Ministry. You are also verifying that all the information on this form is accurate and up to date. You are also verifying that you have an Online Medical Information and Liability and Media Release waiver on file with the church. If you have yet to fill out that form, please do so by visiting mtpulaskicc.org/safe. If you are unsure if you have one of these documents on file, please contact Garrett LeVault at garrett@mtpulaskicc.org. You are also verifying that you understand that the trip costs $300 and you plan to submit payment via cash or check to Garrett LeVault or the Mt. Pulaski Christian Church office before the date of the trip. These checks need to be made out to "Mt. Pulaski Christian Church" and please write "CIY MOVE 2017" in the memo line. Please refer to the 2017 CIY MOVE Fact-Sheet and CIY Financial Information sheet for complete cost information and trip details.
As the parent or legal guardian of the child named above, do you give your child permission to attend CIY MOVE and agree to the permission statement written above?
Please Type Your Full Legal Name (This will serve as your electronic signature)
Your answer
Submit
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