REVERB Registration

REVERB ALL-NIGHTER REGISTRATION PAGE
Participant Name*

First NameLast Name
Participant Phone Number*
Participant Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
Age*
Gender*

MaleFemale
CL Club/School

Abington HeightsPen ArgylBlue RidgeCrestwoodCITY LIFEDunmoreElk LakeLackawanna TrailMid ValleyMontroseMtn. ViewNorth PoconoScrantonStroudsburgSusquehannaValley ViewWallenpaupackWestern WayneWest ScrantonGROVE CHURCHFAITH BAPTIST CHURCHOther
Grade

9101112Other
Primary Emergency Contact Info
Primary Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Emergency Contact
Secondary Emergency Contact Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Medical

In case of emergency
Name of Physician*

First NameLast Name
Physician Phone Number*

Area CodePhone Number
Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I have had a physical within the last 24 months
Medical Insurance Company*
Policy No.*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies (check all those that apply and specific nature of allergic reaction):*

NoneAnimalsEnvironmentalMedicationFoodInsectsLatexOther
Please specify the nature of allergic reaction*
If none, type N/A
Consent and Release of Liability
I represent that I am the participant named below (if 18 or over) or the legal parent/guardian of the child named below, who is under 18 years of age. In consideration for allowing my child to participate in this activity and ongoing YFC activities, I hereby consent to the foregoing on behalf of my child and agree that this release shall be binding upon me, my child, our heirs, legal representatives and assigns.
Participant Signature*

Clear
Participant Name*

First NameLast Name
Date*

MonthDayYear
Date
Parent/Legal Guardian Signature (if participant is under 18)*

Clear
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Phone Number*

Area CodePhone Number
Date*

MonthDayYear
Date
PAYMENT INFORMATION
I want to Pay Online NowI will send a check written to "Campus Life" with Memo: Reverb Reg. (mailed to: NEPA Youth For Christ 1613 Jackson St Scranton PA, 18504)

USD$70 LATE Student Registration

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

Please verify that you are human*
Should be Empty:

REVERB ALL-NIGHTER REGISTRATION PAGE

Primary Emergency Contact Info

Secondary Emergency Contact

Medical

Consent and Release of Liability

PAYMENT INFORMATION

Payment Methods