MOVE 2020
If your child is planning on attending CIY Move through Mt. Pulaski Christian Church please fill out this form. If you have any questions you can contact Nathaniel Dyer at (217)-671-7237, or
Students Name *
Student Phone number
Send/Recieve Text Messages
Clear selection
Grade *
Student Mailing Address *
Parent(s)/Guardian(s) Name(s) *
Parent(s)/Guardian(s) Phone Number *
Parent/Guardian Email Adress *
Emergency Contact Name
Emergency Contact Relationship to Student *
Emergency Contact Phone number *
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 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 are unsure if you have one of these documents on file, please contact Nate Dyer at You are also verifying that you understand that the trip costs $350 and you plan to submit payment via cash or check to Nate Dyer or the Mt. Pulaski Christian Church office before the date of the trip. I will be in contact with you after you complete this form giving you some dates for some deposits. Payment may be paid in full to the church by 6/1/20. These checks need to be made out to "Mt. Pulaski Christian Church" and please write "CIY MOVE 2020" in the memo line. If you have any other questions please contact Nathaniel Dyer.
As the parent or legal guardian of the child named above, do you give your child permission to attend CIY MIX and agree to the permission statement written above? *
Please type your full name in this Box (This will serve as your electronic signature) *
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