SEYP Registration

2023 SEYP Fall Conference

October 27-29; Camp Westminster, Conyers, GA
General personal information
Registrant's name*

First NameLast Name
Gender*

MaleFemale
Locality*
Please write in your locality here:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email address*
If you are a parent completing this form for your child, input your personal email address. If you are a serving one completing the form for yourself, input your personal email address. Do not input the email address of a young person.
Please list any medically-diagnosed food allergies and/or dietary restrictions you may have.
Are you registering a young person or as a serving one?*

Young Person's Grade and Birthday
Child's current year in school*
Child's birthday*

MonthDayYear
Date

Parent and Emergency Contact Information
Parent/guardian's name*

First NameLast Name
Parent/guardian's phone number*
Please enter a valid phone number.
Emergency contact name (other than the parent/guardian completing this form)*

First NameLast Name
Emergency contact's relation to child*
Emergency contact's phone number*
Please enter a valid phone number.

Serving One's Phone and Emergency Contact
Your phone number*
Please enter a valid phone number.
Name of emergency contact*

First NameLast Name
Emergency contact relation to you*
Emergency contact phone number*
Please enter a valid phone number.

Young Person's Medical Information
Child's physician*

First NameLast Name
Physician's phone number*
Please enter a valid phone number.
Child's health insurance company*
Insurance company phone number*
Please enter a valid phone number.
Insurance policy or group number*
Please list and explain any other medical condition your child has, other than the allergies previously listed.

Minor release of liability for the Church in Athens
I, the parent or guardian of the above named child, do hereby release, forever discharge, and agree to hold harmless the Church in Athens, the Church in {locality}, and the staff and volunteers thereof from any liability, claims, or demands for personal injury, sickness, or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said participant is participating in the above described activity.

Furthermore, I assume all risk or personal injury, sickness, death, damage, and expense as a result of participation in transportation, recreation, and work activities involved therein.

The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees, and agents, for any liability sustained by said church as the result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto.

I further grant my permission for my child to participate fully in the above described activity and hereby authorize the bearer of this document to obtain and direct any and all medical and/or emergency care which in the bearer’s opinion is needed by my child. By signature hereto I hereby release and hold harmless the Church in Athens and the Church in {locality} of any and all liability with respect to any medical care, medical decisions, treatment, or matters that may arise. I also accept full responsibility for the payment of any expenses incurred from such medical and/or emergency care.
Parent/guardian signature*

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Date*

MonthDayYear
Date

Adult release of liability for the Church in Athens
I do hereby release, forever discharge, and agree to hold harmless the Church in Athens, the Church in {locality}, and the staff and volunteers thereof from any liability, claims, or demands for personal injury, sickness, or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said participant is participating in the above described activity.

Furthermore, I assume all risk or personal injury, sickness, death, damage, and expense as a result of participation in transportation, recreation, and work activities involved therein.

The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees, and agents, for any liability sustained by said church as the result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto.
Signature*

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Date*

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Date
ZAPIER Email*
example@example.com
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2023 SEYP Fall Conference

General personal information

Young Person's Grade and Birthday

Parent and Emergency Contact Information

Serving One's Phone and Emergency Contact

Young Person's Medical Information

Minor release of liability for the Church in Athens

Adult release of liability for the Church in Athens