CIY MIX 2020
Please fill this out for each child planning to attend CIY MIX through Mt. Pulaski Christian Church please fill out this form. If you have any questions, please contact Nate Dyer @ (217)671-7237 or
Student Name *
Student Phone Number (If Applicable)
Send/Receive Text Messages?
Clear selection
Grade *
The grade the student will be entering in the fall of 2020.
Student Mailing Address *
Parent(s)/Guardian(s) Name(s) *
Parent(s)/Guardian(s) Phone Number(s) *
Parent/Guardian Email Address *
Emergency Contact Name *
Emergency Contact Relationship to Child *
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 MIX 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 $325 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 6/20/20. These checks need to be made out to "Mt. Pulaski Christian Church" and please write "CIY MIX 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) *
Never submit passwords through Google Forms.
This form was created inside of Mt Pulaski Christian Church. Report Abuse