DNOW Registration Form

DNOW

REGISTRATION FORM
Disciple Now will be here before we know it! We are excited for this year's event and all that it has in store for its participants! The event will take place October 17th and 18th at Redeeming Grace Baptist Church and is $40 per student. Registration is really easy with this smart registration form.
What church are you signing up with?*

Forged - Leonardtown Baptist ChurchImpact Youth - Lexington Park Baptist ChurchLibertad Baptist ChurchRedeeming Grace Baptist ChurchYouth Impact - Southern Calvert Baptist ChurchSASYF Outbound YouthPatuxent Presbyterian ChurchOther
Is Participant?*
Name*

First NameLast Name
Nickname
Birth Date*

MonthDayYear
Grade*
Gender*

MaleFemale
Participant's Phone Number*
(xxx) xxx-xxxx
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent's/Guardian's Name*

First NameLast Name
Cell Number*
Parent's/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Is your child prescribed any medication? If yes, please explain any instructions.*
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Disciple Now during the weekend. In exchange for the acceptance of said child’s candidacy by Disciple Now, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Disciple Now and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected sessions.

In case of injury to said child, I hereby waive all claims against Disciple Now including all affiliates, all participants; and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in activities. Some of these injuries include but are not limited to, the risk of fractures, paralysis, or death.

I hereby grant Disciple Now and its affiliants to permission to use photography and videography of my child for the purpose of publication, promotion, and advertising in any manner or medium.
Medical Release and Authorization

As Parent and/or Guardian of the above named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Disciple Now and its affiliates to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered trip.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
T-Shirt Size*

SmallMediumLargeXL2XL3XL
My Products*
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Student Registration$40.00
Please provide payment directly to your Youth Director

Leader Registration$ Free

Total $0.00
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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