Student Registration- West Virginia Trip- June 15-22, '19
Cost is $125 per 8th-12th grade student (Scholarships Available)

Checks are payable to “Bethany Church” (note WV Mission Trip on memo).

Scholarships are available. We do not want to see anyone not going because of finances.

Registration forms, a $50 deposit, and T-Shirt size by Sunday, May 5, 2019 to receive preference for your placement. Registration will remain open until 6/7.

Questions? Please contact: Dan Cameron at 724-854-3052 or Nate Childers 724-974-9250.

Email address *
STUDENT REGISTRATION INFORMATION
Student's Name (First & Last) *
Your answer
Gender
Grade: *
Tentmate Request
Your answer
Birthday *
MM
/
DD
/
YYYY
Preference in VBS Age Group
T-Shirt Sizes
Student's Address *
Your answer
Parent's Mobile Phone: *
Your answer
Please list any physical or other conditions requiring medication, treatment, or special requirement(s): *
Your answer
Please list any allergies (bee stings, nuts, etc.) or dietary restrictions:
Your answer
Insurance Carrier: *
Your answer
Insurance ID/Policy #
Your answer
Insurance Phone #: *
Your answer
Church Affiliation
Your answer
Emergency Contact Name *
Your answer
Emergency Phone Number *
Your answer
COST
Cost is $125 per student. Please make payments out to "Bethany Church" (100 W. Venango St. Mercer, PA 16137) and turn them in to the Bethany Church office by ______________________. Need based and multi-child scholarships are available. Please e-mail nate@bethanymercer.org.
TRANSPORTATION
Transportation is provided by a Watson bus on Saturday, Nov. 17 at 7:15 am and Sunday, Nov. 18 at 3:00 pm. Special transportation will be provided on Friday evening for the 5th & 6th grade attending. Please let us know below if you need to drop off late, pick-up early, and what date/time.
LIABILITY RELEASE
I give permission for my child to be transported to and attend West Virginia Trip with Bethany Church. I release Bethany Presbyterian Church, as well as employees and volunteers from any and all claims or liability arising out of this participation. In case of emergency involving my child, I understand every effort will be made to contact me. In the event that I cannot be reached, I allow the adult leader to select a medical provider to secure the proper treatment of my child at my expense. This includes hospital visits, injections, and/or medication.
MEDIA RELEASE
I understand that the image and/or voice of my child may be recorded while attending programs and activities with Bethany Church, Mercer, PA. I give my consent to the use of any type of media recording of my child for any editorial and/or promotional material by Bethany Church and/or partnering organizations while attending said programs and activities.
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