Youth Mission Trip - 2024
July 8-13 | $365 | Fill out the form carefully for registrations. For scholarship information please contact Jo Ann in the church office before attempting to register. You can contact her at 940-692-4220 or joannl@faithwf.com.
Student Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Grade
*
Please Select
7th
8th
9th
10th
11th
12th
Parent Name
*
First Name
Last Name
Parent Email
*
example@example.com
Parent Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Phone Number
Student T-shirt size
*
Please Select
S
M
L
XL
2XL
3XL
4XL
Payment:
Please note that a 3.5% processing fee will be added to any online registration. If online payment is selected, you will be redirected after the release form and asked to sign in or briefly create an account (unless you choose to pay in person.)
Payment Method:
*
Online Registration ($377)
Pay in person ($365)
Already Paid
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Medical Release Form
This medical release form is required for Faith Baptist Church Student Ministry events. If any of the information changes, it is the parent/guardian's responsibility to update the information through the church office.
Secondary Contact in case of emergency
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Relationship to student
*
Please supply the following information:
Medical Insurance Information (Company, Group #, Policy #, Company address, etc.)
Attach photo of insurance card (front)
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Physical Limitations (Asthma, diabetes, allergies, etc.) and/or special instructions (allergic to certain meds, rare blood type, food allergies, etc.)
Please list any medications taken on a regular basis and/or any brought with student to event. (Prescription meds must have a pharmacy label and name of doctor).
Emergency Authorization
I hereby give permission to medical personnel selected by Faith Baptist Church Wichita Falls. Group Sponsor or camp staff to order X-rays, routine tests, and treatment for my child attending the ministry event. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in a church activity. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury. I understand that there are risks involved in taking place in recreation activities and other activities related to participation in youth functions.
Signature of Parent/Guardian
Date:
-
Month
-
Day
Year
Date
Should be Empty: