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Winter Youth Retreat at Akita Registration Form

Permission

I/We do hereby give permission for my/our above named child to be transported by Broad Street Presbyterian Church to attend and participate in the Presbytery of Scioto Valley Winter Youth Retreat at Camp Akita from February 22-24, 2019.

I, the undersigned, being the parent or legal guardian of the child named above, permit my child to participate in all camp activities and certify that the above information is correct. I give permission for my child/me to be photographed during camp activities and for the Presbytery to use such photographs in publicity. I give permission for PSV to administer prescribed medications and provide routine health care. I understand the presbytery will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. In the case of accident/injury, I give PSV permission to seek medical attention for my child/ me and arrange necessary transportation and I understand that if my child needs emergency care that PSV will attempt to contact me immediately.

Church: Broad Street Presbyterian Church

Today's Date: July 21, 2019

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Mark One:*

Grade:

Special Accommodations / Dietary needs /Allergies / Medications:
T-shirt Size
Adult Small
Adult Medium
Adult Large
Adult XL
I do not want a t-shirt.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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