Youth Encounter Retreat – Student Registration Name(Required) First Last Indicate which of the following describes you(Required) Male Female What Grade Are You Currently In?Please Select6th7th8th9th10th11th12thWhat is Your Age?(Required)What is Your Youth Group Name?(Required)What is Your Email?(Required) What is Your Phone Number?What is Your Parent/Guardian's Name? First Last What is Your Parent/Guardian Email?(Required) What is Your Parent/Guardian Phone Number?Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Name(Required) First Last Emergency Phone(Required)Physician Name(Required) First Last Physician Phone(Required)Health Insurance Provider(Required)Health Insurance Policy Number(Required)Please list any Medical Conditions, Allergies, Disabilities or Impairments that should be disclosed to any medical provider should a medical need arise at Youth Encounter Retreat:(Required) NO INDIVIDUAL WILL BE REGISTERED OR ADMITTED TO YOUTH ENCOUNTER RETREAT WITHOUT COMPLETING AND SIGNING THE FOLLOWING. Liability & Medical Release Each student registrant must have his/her parent or guardian sign this release. Each adult registrant must sign the release: Having been made aware of the activities the registrant will be doing, I hereby consent to the registrant's participation in YOUTH ENCOUNTER RETREAT. I indemnify, defend and hold harmless the LifeChurch and Christian Assembly for all claims and liabilities assessed against them as a result of the registrant's activities. Further, in case of emergency, I understand that every effort will be made to contact parents or guardians of minors' registrants. However, if parents or guardian cannot be reached, or if I, (the below signed registrant) am 18 years of age or older, I hereby give LifeChurch and Christian Assembly and or group leader permission in seeking medical treatment in the event that such treatment is deemed necessary or advisable to the registrant's health, safety, and welfare. I give permission to those administering medical treatment to do so, using the measures deemed necessary. I release LifeChurch and Christian Assembly and all medical providers from any injury resulting from the registrant's activities. RECORDING RELEASE: In registering for YOUTH ENCOUNTER RETREAT 26, I give permission to YOUTH ENCOUNTER RETREAT 26 and its video/audio production staff to use your name, voice, video image and/or photo in future promotional pieces, broadcasts, and the YOUTH ENCOUNTER RETREAT website. I agree to the terms and conditions above:(Required) I agree I am signing as the:(Required) Parent Guardian Student (must be 18 years old) Signature(Required)YE26 - Student Admission (early registration until 2/28, 11:59 pm) Price:
