Youth Participant Registration
Youth Retreat February 20 7 pm - February 22 9:30 am
Church
*
Cahaba Springs
Edgewood
First, Auburn
First, Birmingham
First, Livingston
First, Tuscaloosa
First, Wetumpka
First United, Birmingham
Grace
Immanuel
Independent
Mountain Brook
Oakmont Chapel
South Highland
Southminster
Westminster, Bham
Other
If Other, what church will you be attending with
Youth Name
*
First Name
Last Name
Grade
*
please select
6
7
8
9
10
11
12
Child with adult advisor
Age of child
Youth Council
Yes
No
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/guardian Name (Emergency Contact 1)
*
First Name
Last Name
Parent/guardian Cell Phone Number (Emergency contact 1)
*
-
Area Code
Phone Number
Parent/guardian email
*
example@example.com
Church Youth Advisor/Chaperone
*
Name
Advisor/Chaperone Email
*
example@example.com
To be filled out by Parent/Guardian of Participant
List any DIETARY allergies/ restrictions
*
If none, please enter none
I require a epipen
*
Yes
No
List any non-Dietary allergies (bee stings, etc)
*
If none, please enter none
I require an inhaler
*
Yes
No
List any medical or other conditions leadership team should be aware of.
*
If none, please enter none
Medical Authorization and Release
*
Should my child sustain or incur any accident or illness while at the event, I hereby authorize the Director,the Health Care provider or chaperone to execute any and all documents in my behalf, including necessary releases, which might be required by a medical facility to perform emergency care.
I do not give permission
Photo release and permission to contact
*
I give permission for any photos or videos taken of my child during the event to be used by the Presbytery of Sheppards and Lapsley and/or Living River for use of the public relations of the program.
I do not give permission
Accident Insurance Disclaimer
*
I understand I am responsible for all incurred medical expenses while my child is a participant at Living River
Community Guidelines
*
I understand I will receive an email with information about what items to bring or not to bring to the retreat as well as community expectations for the weekend. I understand my child is responsible for knowing and adhering to these and may be sent home if not in compliance.
Parent Signature
*
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Payment
Type payment -- Cost $80
*
Bill the church
Pay by check - Payable to Presbytery of Sheppards & Lapsley
Pay by credit card
Bill Presbytery
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**Credit card Payment
****** IMPORTANT -- Please click "add to cart" box below
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Please submit your registration! See you at Living River.
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