WIRED WEEKEND REGISTRATION 2023

WIRED WEEKEND REGISTRATION 2023
Before you can have your mind blown by WIRED WEEKEND, we need a few things from you first. Complete this registration form to get things rolling.

WIRED WEEKEND 2023 will be September 2-4. Registration begins Saturday, September 2 from 12-2pm. WIRED WEEKEND will end on Monday, September 4th at noon.

The Cost/Student will be $75 and will be paid at registration (ages 12-25). This covers room/board, food, T-shirt, and activities. Students will need money for travel and any additional activities (i.e. extra games, extra food from off-campus activities).

For any additional information, please contact:
Dee Stone - 479.857.7563
Kim Stone - 479.280.3316
Personal Info

(but not too personal)
Name*

First NameLast Name
Gender*

MaleFemale
Age*
Must be between 12-25
T-shirt Size
Phone Number
Only if you want to...
Parent's Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Church
Pastor or Youth Pastor
Medical Info

(it won't hurt)
Any allergies we need to know about (food, meds, nature, etc.)?*

YesNoWe'll find out I guess
Tell us more about these allergies.*
Any medications we need to know about?*

YesNo
Tell us more about these meds (a list would be perfect).*
Insurance Info

(just in case)
Insurance Provider
Group Number
Policy/ID Number
Subscriber Name
Subscriber Phone
Please enter a valid phone number.
Subscriber Employer
Subscriber Work Phone
Please enter a valid phone number.
Medical Release
By signing this form, I, the undersigned, do give my permission for the WIRED WEEKEND director, medical staff, adult present or in charge of first aid, or church official responsible for transporting my child to and from the event to provide medical treatment in the case of sickness or injury to my child, while on or in route to the event location.

WIRED WEEKEND is staffed with a Licensed Registered Nurse. If the staff at WIRED WEEKEND, see that my child needs medical attention that the camp health professional cannot give, the emergency contact listed above will be notified and my child will be taken to a nearby hospital. WIRED WEEKEND is not responsible for any injury my child may experience while he/she is on location.

I, the undersigned, will be responsible for all medical treatment and/or medications that may be necessary, beginning the first day of WIRED WEEKEND and continuing until the end of the event. The Associated Brotherhood of Christians, Jesus Name Church, or any of its officials or staff will not pay for or be responsible to pay for any medical treatments or medications. All responsibility will lie with the parent, legal guardian, or adult that signs this document. I acknowledge that I have completely understood this release statement and all its terms and by checking the box below, I consent to the use of this e-signature and understand that by e-signing I am legally bound to the terms of this document.
*

I agree to the terms and conditions above
Should be Empty:

WIRED WEEKEND REGISTRATION 2023

Personal Info

Medical Info

Insurance Info

Medical Release