HPBC Disciple Now Registration
February 10th-12th
Student Name *
Your answer
Student Grade *
Your answer
Student Birthday *
MM
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DD
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YYYY
Student Age *
Your answer
Student Address - Number and Street *
Your answer
Student Address - City *
Your answer
Student Address - Zip Code *
Your answer
Student Cell Phone Number *
Your answer
Parent/Guardian(s) Name *
Both parents if you live with both
Your answer
Parent/Guardian(s) Phone Number *
Both parents if you live with both
Your answer
Parent/Guardian(s) Email *
Both parents if you live with both
Your answer
Adult Size Shirt *
Student- Are you a member of High Pointe? *
Your answer
If not, do you attend another church? What Church?
Your answer
Student- Which friend invited you to DNOW?
Your answer
List of Allergies *
Your answer
List of Medications and Schedule *
Your answer
Do you have asthma? *
Do you have an Inhaler? *
If yes, will it be with you?
Please write any additional medical or personal information including activities you do not wish your child to participate. *
Your answer
Does your student have permission to drive their own car during the weekend? *
Does your student have permission to ride with another YOUTH during the weekend? (this is only to leave for the weekend not for DNOW events. Example: Sporting or school event) *
Your answer
Please list all the dates and times you will need to be away for Disciple Now Weekend: *If Applicable
Your answer
Students Doctor's Information: Doctor’s Name *
Your answer
Students Doctor Information - Doctor's Phone # *
Your answer
Students Insurance information- Company *
Your answer
Student Insurance Information- Policy # *
Your answer
Medical Release- Parent First and Last Name for online Signature. PARENT/GUARDIAN PERMISSION I hereby give my permission for my child to take part in various sponsored trips, outings and camps with High Pointe Baptist Church. I further give my permission for the designated/approved church representative or sponsor to secure any needed/necessary medical treatment(s) for the above named son/daughter. I release the church representatives or sponsors from liability for accident or injuries on these trips or activities.In the event that the above named son/daughter be involved in any non-Christian or dangerous activities, I agree to pay for him/her to be sent home immediately at the discretion of the approved sponsors and/or the church representative. *
Your answer
Parent/Guardian Online Signature: *
Your answer
Student Online Signature: *
Your answer
Comments and/or questions
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