Regional Youth Conference

Regional Youth Conference

April 10-12, McPherson College Campus and McPherson Church of the Brethren
Student Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Local Church/Congregation Affiliation
Parent/Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Will this be the emergency contact for the student attending? If no, please add an emergency contact below.

YesNo (please add emergency contact below)
Emergency Contact Info.

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I(parent/guardian name)* consent for my student (student name) blank* to attend and participate in the Regional Youth Conference, held at McPherson College and McPherson Church of the Brethren. I release McPherson College, McPherson Church of the Brethren, The Church of the Brethren Denomination, and the Western Plains District of the Church of the Brethren from liability in the event of accidental injury or other unforeseen circumstance that may occur at this event. I understand that student lodging will be at McPherson Church of the Brethren and my student will be responsible for their own bedding (mattress/sleeping bag). I understand that my student will be responsible for self-administering any prescribed medication. I further understand that while adult supervision will be present, my student is responsible for their safety and conduct while attending this event. Signature*
Please select which meals the student will be present for:

Friday Evening SnackSaturday BreakfastSaturday LunchSaturday DinnerSaturday Evening SnackSunday Breakfast
Please list any food allergies or dietary restrictions
Please list any medications you take or medical concerns we should be aware of:
Is your student willing to assist with Sunday morning worship?

YesNo

My Products*

Regional Youth Conferece

Registration fee

$100.00 Quantity

Total

$0.00

Credit Card

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