Winter Retreat Registration

COMPLETE THE FOLLOWING FORM BY ANSWERING EACH QUESTION, OR FILLING OUT THE PROPER RESPONSE WHERE INDICATED.
LAST NAME *
WHAT IS STUDENT's LAST NAME
Your answer
FIRST NAME *
WHAT IS STUDENT's FIRST NAME
Your answer
AGE *
HOW OLD IS THE STUDENT?
Your answer
STUDENT GENDER *
STREET ADDRESS *
WHAT IS YOUR HOME ADDRESS
Your answer
CITY *
WHAT CITY DO YOU LIVE IN?
Your answer
ZIP CODE *
WHAT IS YOUR ZIP CODE?
Your answer
PHONE # *
WHAT IS YOUR PHONE NUMBER?
Your answer
YOUTH GROUP
WHAT YOUTH GROUP DO YOU GO TO?
Your answer
IN AN EMERGENCY, NOTIFY: *
WHO SHOULD WE CALL IN AN EMERGENCY?
Your answer
EMERGENCY PHONE# *
WHAT IS THE BEST # TO REACH YOUR EMERGENCY CONTACT?
Your answer
FRIEND OF:
WHO ARE YOU CALLING YOUR FRIEND IN ORDER TO GET A DISCOUNT
Your answer
MEDICAL CONDITIONS *
LIST ANY MEDICAL CONDITIONS WE SHOULD BE AWARE OF
Required
EXPLAIN CONDITION
PLEASE EXPLAIN ANY NOTED MEDICAL CONDITION AS WELL AS MEDICATION AND PRECAUTIONS
Your answer
DATE OF LAST TETANUS SHOT *
WHEN WAS YOUR LAST TETANUS SHOT
Your answer
INFECTIOUS DISEASE EXPOSURE *
PLEASE NOTE TO THE BEST OF YOUR KNOWLEDGE, HAS HE/SHE BEEN EXPOSED TO THE FLU OR ANY OTHER INFECTIOUS DISEASE WITHIN THE LAST 3 WEEKS?
INSURANCE COMPANY *
PLEASE LIST THE NAME OF YOUR HEALTH INSURANCE COMPANY
Your answer
POLICY HOLDERS NAME *
WHO IS THE PRIMARY CARD HOLDER FOR YOUR INSURANCE POLICY?
Your answer
POLICY # *
WHAT IS YOUR INSURANCE POLICY NUMBER?
Your answer
PARENT: CONSENT FOR MEDICAL TREATMENT *
BY TYPING YOUR NAME BELOW YOU HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY JASON NEWBY OR ANY STAFF HE AUTHORIZES, TO HOSPTIALIZE / SECURE PROPER TREATMENT FOR AND / OR TO ORDER INJECTION, ANESTHESIA, OR SURGERY FOR YOUR CHILD NAMED ABOVE, IN THE EVENT OF AN ACCIDENT OR EMERGENCY
Your answer
PARENT: CHURCH LIABILITY RELEASE *
BY TYPING YOUR NAME BELOW YOU HEREBY GIVE PERMISSION FOR YOUR CHILD TO ATTEND WINTER RETREAT DEC 30 - JAN 1 2017, AND RELEASE AND DISCHARGE THE EVANGELICAL FREE CHURCH OF EATON, ITS AGENTS, DRIVERS, SPONSORS, EMPLOYEES, MEMBERS, AND OFFICERS FROM ANY AND ALL ACTIONS, CLAIMS, JUDGEMENTS, AND EXECUSTIONS THAT MAY ARISE OUT OF THIS ACTIVITY
Your answer
Payment Method *
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