Epic Encounter 2021

Name*

Age:*

Church:*

Chaperone:*

PARENTAL CONSENT: (If under 18 years of age)

In case of an emergency, I understand that every reasonable effort will be made to contact me. In the event that I cannot be reached, I give permission to the physican selected by the adult leader/ chaperone in charge to secure proper treatment for my child.

Give permission to treat my child:*

YESNO

Signature*

Emergency Contact:*

Phone:*

Relation:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Room: List the names of who you are sharing the room ( 4 people)*

T-shirt size:

Early Bird $45.00

How many people

Total

Epic $75.00

How many people

Calculation

Paying by CHECK:*

YESNO

Check#

My Products

Early Bird ( until Oct. 31) $45.00

Quantity

Epic Encounter $75.00

Quantity

Total $0.00

Credit Card