Challenge 2010: UNDO..restoring the original

This is the EFCA Youth Conference
June 28-July 3, 2010 in Columbus, OH
Total cost $600

See Conference Brochure -->HERE<--

There is a $150 dollar registration fee due by Sunday, April 11, 2010
The final balance after the registration fee is $450, which is due by Sunday, May 23, 2010

For more information, contact Wayne Hanson
Phone: (608) 873-9838
E-mail: wayne@lakevc.org

*** If you have already signed-up online but have not paid, ***
or
If for any reason, you believe you have not filled out the application, but do not
see the form below, e-mail Austin Johnson at: austin@lakevc.org

Student Info

Name: *

Gender: *

Male

Female

E-Mail:

Cell Phone Number:

Birthdate: *

Age: *

Grade: *

School: *

Parent Info

Name: *

Address: *

City: *

State: *

ZIP: *

Home Phone:

Work Phone:

Cell Phone:

E-Mail:

Medical Info

Special Medications, Allergies, or Other Important Information that their leader should know:

Family Doctor/Name of Practice :

Doctor's Phone:

Insurance Company:

Group Number:

Policy Number:

Other Emergency Contact: *

Please include a name, phone number, address and relationship to the student

2nd Student Info

If you are registering more than two people, please contact Julie Speth at
julie@lakevc.org

Name:

Gender:

Male

Female

E-Mail:

Cell Phone Number:

Birthdate:

Age:

Grade:

School:

2nd Student Medical Info

Please fill out if anything is different from above

Special Medications, Allergies, or Other Important Information that their leader should know:

Family Doctor/Name of Practice :

Doctor's Phone:

Insurance Company:

Group Number:

Policy Number:

Other Emergency Contact:

Please include a name, phone number, address and relationship to the student

I/We give consent: *

I/We understand that in the event medical intervention is needed while under the care of LakeView Church, every attempt will be made to contact immediately the persons listed on this form. In the event I/We cannot be reached, I/We hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order an injection, anesthesia, or surgery for the student as deemed necessary.

I/We further agree to hold the licensed physician, the medical facility, LakeView Church and its representatives free and harmless of any claims, demands or suits for damages arising from the authorization and provision of such medical treatment.

I/We understand the nature of the event and do hereby release LakeView Church and its representatives from any liability due to accident or injury incurred by my child.

I/We understand all reasonable safety precautions will be taken at all times by LakeView Church Student Ministries and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold LakeView Church and its representatives liable for damages, losses, diseases, or injuries incurred by the subject of this form.

I/We agree to cover all costs if our student needs to be sent home for disciplinary reasons.

By selecting YES above, you release to LakeView Church the rights to photos, video or other images of this student for use in church publications.

Also by selecting YES above, you agree that you have read this statemnet fully and that you are the legal guardian of the above mentioned student.