Youth Boot Camp Registration Form

Youth Boot Camp Registration Form
HeartLink Network is proud to offer all youth in grades 6-12 another summer Boot Camp experience. Boot Camp is not only a fun and challenging event, but one where youth encounter God's love, acceptance, and forgiveness.

Boot Camp will be held in Rockingham County, Virginia on the beautiful property of Bob & Ruthie Vander Lugt, members of Cornerstone Church of Harrisonburg.

Cost for Boot Camp is $100 per person. Discounts are given for families with multiple registrants. Payments are as follows:
- $100 (1 child)
- $175 (2 children)
- $250 (3 children)
- $325 (4 children)
A link for payment is located at the bottom of the registration form.

If you are in need of financial assistance, please contact your local pastor or youth leader to make your need known.

On behalf of the event leadership team, we look forward to seeing your child at Boot Camp.

Blessings,

Pastor Greg Mayo

** Registration must be completed separately for each youth.

** Payment can include all youth being registered.
YOUTH INFORMATION
Name *

First Name Last Name
Gender *

Male Female
Date of Birth *

Month Day Year
Date
Current School Grade *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
T-Shirt Size *
Your Home Church *
Your Youth Leader's Name *
PARENT INFORMATION
Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
YOUTH MEDICAL INFORMATION
Medical History (include information leaders need to be aware of) *
Allergies *
Medications *
Insurance Name *
Insurance Policy Number *
Insurance Group Number
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Phone # *
MEDICAL EMERGENCY PERMISSION
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases HeartLink Network and its staff of any liability against personal losses of named child.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by HeartLink Network. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release HeartLink Network, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by HeartLink Network, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Signature *

Clear
Date *

Month Day Year
Date
PAYMENT

Please use the link below to make your registration payment.

https://donorbox.org/youth-boot-camp-2022

If you prefer to pay by check, please make checks payable to HeartLink Network. Please include a note with name(s) of youth the payment is to be applied to.

Mail checks to:

HeartLink Network

PO Box 511

Fishersville, VA 22939
Should be Empty:

Youth Boot Camp Registration Form

YOUTH INFORMATION

PARENT INFORMATION

YOUTH MEDICAL INFORMATION

MEDICAL EMERGENCY PERMISSION