Reality Conference Registration

Reality Conference
Are you registering as a..*

ChaperoneStudent

Personal Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parental Consent Form
Description and Dates of Activity:*
Child’s Name:*

First NameLast Name
Age:*
Birth Date:*
Grade:*
Name of Parent/Guardian(s):*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Phone Contact Number(s):*
Please enter a valid phone number.
Please enter a valid phone number.
Emergency Contact (other than parent/guardian):
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Health/Medial Insurance Co:*
Policy Number:*
List Allergies or Medical Conditions:*
Any Prescription Medications being taken at this time:*
As a parent/legal guardian of type child's name*, I have reviewed the information about the event, and give permission for the subject of this release to be involved I the overall activities.

I/We have reviewed the rules of the activities and agree that the subject of this release will abide by them. I/We also acknowledge that if the subject of the release must return home early for discipline violations, it will be at my/our expense.

I/We understand all reasonable safety precautions will be always taken by Southern Calvert Baptist Church and its agents during the events and activities. I/We authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency.

I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold Southern Calvert Baptist Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
Signature*

Clear
Date*

MonthDayYear
Date

Payment
My Products (select one)*
prevnext( X )
Student RegistrationCost per student + service fee
$66.82



Multi-Student RegistrationMulti-student discount + service fee
$51.52 Quantity



Chaperone RegistrationCost per chaperone + service fee
$41.31



Driver
$ Free



Total

$0.00
Payment Methods

Choose from one of the PayPal options to make your payment.
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Reality Conference

Personal Information

Parental Consent Form

Emergency Contact (other than parent/guardian):

Payment