Youth Impact King's Dominion

King's Dominion Registration
Participant's Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Grade*
Gender*
Participant's Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Participant?*
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
T-Shirt Size
Registration Fee*
prevnext( X )
Registration FeeRegistration + Service Fee
$20.91

Total

$0.00

Payment Methods

Debit or Credit Card

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

Should be Empty:

King's Dominion Registration

Participant's Information

Emergency Contact (other than parent/guardian):