REGISTRATION FORM
Youth Retreat: MISSION POSSIBLE
August 7-9, 2009
TURN IN BY: July 26, 2009 to aaron@revivethecity.org

Name: __________________________________________________

Address: _________________________________________________
_________________________________________________

Email: _____________________ Facebook: Yes/No

Home Phone: _(____)__________ Cell Phone: _(____)__________

Age:_______ Grade completed May 2009:___________

Please describe any food allergies: _____________________________________
_____________________________________

Mother/Guardian Name: ______________________ Daytime Phone: (____)_________
Alt. Phone: _(____)__________

Father/Guardian Name: ______________________ Daytime Phone: (____)________
Alt. Phone: (____)__________




Allergic to the following: (write “none” if no allergies)______________
_______________________________________________________
Restrictions on activities (if any):______________________________
________________________________________________________
Emergency Contact:_______________________________________
(Relation to student):______________________________________
Emergency Contact Phone:__________________________________

Insurance Carrier or Plan Name:
_______________________________________________________
Group #: ______________________________________________
Name of Insured: _______________________________________

In case of medical emergency, I understand every effort will be made to contact parents or guardian. In the event I cannot be reached, I hereby give permission to the physician selected by the
Abbotts Creek Missionary Baptist Church staff to hospitalize, secure treatment for and to order injections, anesthesia, x-rays or surgery for the person named above. My insurance will cover these as the primary carrier. I give permission or my child to participate in the activities of the Youth Retreat.
_______________________________________________________
Signature of Parent/Guardian
_______________________________________________________
Print Name/ Date

Legal Guardian: As the legal guardian, I give my permission for my student to attend the Abbotts Creek Missionary Baptist Church youth retreat taking place August 7-9, 2009. I understand that this involves my student staying over at a “host home” of a church member and will be provided transportation to and from the church and around the High Point area for activities.
_______________________________________________________
Signature of Parent/Guardian