AIM 2025 Registration Form

1
AIM 2025 IS HERE!!!!!
2
Is this registration for a child or youth group attending AIM?* This field is required.
Yes
No
3
Name* This field is required.
First Name
Last Name
4
Parent or Youth Leader Name* This field is required.
First Name
Last Name
5
Email* This field is required.
example@example.com
6
Are you registering under a group?* This field is required.
Yes
No
7
What auxiliary are you registering under? * This field is required.
Please Select
Please Select
Evangelism
Missions
Music
Sunday School
Youth
Not Applicable
8
Are you interested in becoming a AIM Youth Counselor?
YESNO
9
Please indicate the group you are registering with, ex. New Mount Joy Youth Ministry, GET Impact Youth Ministry
10
Group Registration* This field is required.
11
Child's Name * This field is required.
First Name
Last Name
12
Parent's Name* This field is required.
First Name
Last Name
13
Parent's E-mail* This field is required.
example@example.com
14
Will this child be staying in the hotel (platinum registration only and must be 12+ if rooming with other kids)* This field is required.
Yes
No
15
Does the child have any allergies, chronic illness, or medical conditions? If yes, please provide instructions on when and how much to take medication.
16
Who is your district superintendent?* This field is required.
Please Select
Please Select
Anthony Daniels
Barry Winston
Duane McNair, Sr
Joseph T. Williams
Larry C. Miles, Sr
Lemuel Williams
Michael B. Golden, Sr
Raymond Johnson
Robert Gay, Sr.
Samuel Braxton
Samuel Green, III
Theodore Hughey
Thomas Campbell
Timothy Williams
Trevon Boone
Tyrone Scafe, Sr
Waddee Thoroughgood
William Mosby
William Ward
Ronald Watson
17
Who is your pastor? (Title, First Name, Last Name)* This field is required.
18
What church is the child a member of?* This field is required.
19
Please Provide Child's Age Group (Hotel for Children 12+)* This field is required.
15-17
12-14
9-11
5-9
20
Gender of child?* This field is required.
Male
Female
21
Birth Date* This field is required.
Month
Day
Year
22
Emergency Contact Phone Number* This field is required.
23
Emergency Contact's Name* This field is required.
First Name
Last Name
24
T-Shirt Size* This field is required.
Please Select
Please Select
KID'S S
KID'S M
KID'S L
S
M
L
XL
2X
3X
4X
5X
25
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by 2nd Ecclesiastical Jurisdiction of Virginia during AIM 2025. In exchange for the acceptance of said child’s candidacy by 2nd Ecclesiastical Jurisdiction of Virginia. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless 2nd Ecclesiastical Jurisdiction of Virginia. 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 camp sessions.

In case of injury to said child, I hereby waive all claims against 2nd Ecclesiastical Jurisdiction of Virginia . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
26
Medical Release and Authorization

As Parent and/or Guardian of the named attendee, 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 athlete. 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 the 2nd Ecclesiastical Jurisdiction of Virginia. and its affiliates including Directors, Coaches, and Team Parents 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 season.

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.
27
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. THIS SIGNATURE ALSO SERVES AS ACKNOWLEDGEMENT THAT THE APPROPRIATE REGISTRATION FEES HAVE BEEN PAID OUTSIDE OF EVENTBRITE PORTAL.
28
Date
Date
Month
Day
Year
29
Signature* This field is required.
Clear
30
My Products* This field is required.
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Registration
$150.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Total cost $0.00
31
Pay with PayPal
Choose from one of the PayPal options to make your payment.
Should be Empty: