YOUTH DISTRICTSJANUARY 3-5, 2020GREEN BAY, WICOST: $150 - includes transportation, lodging, & breakfast.
TWO OPTIONS TO PAY: (Debit or Credit Card ONLY with this form.)
- Pay Now (Full Payment): $150 NON-REFUNDABLE
- Pay Now Scholarship Request: (I am requesting a Scholarship. I understand it is not guaranteed and that the amount will be 50% or less of the cost of the trip. I am including a 50% share of the total cost as a deposit): $75 NON-REFUNDABLE
**It is recommended that the student bring an additional $30-60 for other meals.
-Requirements: ONLINE REGISTRATION, PAYMENT, HEALTH INFO, & WAIVER (see below)
-Should be filled out by youth AND/OR youth's parent/guardian
>>> ABSOLUTE DEADLINE! (no exceptions):
WEDNESDAY, NOVEMBER 13th <<<
For questions, contact Katy at firstname.lastname@example.org.
YOUTH MEDICAL/HEALTH INFORMATION
Pertinent Past Medical History (If there is no medical history that we should be aware of or that may affect this youth due to being away from home, please answer "none".)
Current medications, dosage, & frequency (Please list MEDICATION NAME, DOSAGE, and FREQUENCY. If there are no medications, please answer "none".)
Any known allergies and treatment (If there are no known allergies, please answer "none".)
In case of emergency contact information: If the emergency contact is the Parent/Guardian above, please answer "see above" in the Emergency Contact Name box below. If you would like a different or an additional contact, please list here:
Medical Treatment Authorization
In case of an emergency, I give permission to medical personnel to do whatever is necessary for this youth's medical care. (If you agree, please answer with your FULL NAME here. If you have any comments regarding this permission, please add them below. If you do not agree, please answer "do not agree" and explain in comment section below.)
I understand that direct supervision of my youth by First Free Church will be limited by the nature of the activity. I understand the risks involved, and I absolve First Free Church from liability to me or my youth because of injury, accident, or illness while attending the 2020 Districts Youth Conference. I also authorize First Free Church Youth Leaders to secure necessary emergency medical treatment for my youth in the event of injury/illness while on this trip. I understand youth may be photographed or videotaped during conference activities. These pictures/videos may be used for presentation during the conference, in our promotional materials, on the Forest Lakes District website or social media outlets. I give my permission for my child to be photographed and videotaped.
Parent/Guardian Agreement & Permission
I agree to all of the above & give my permission to this youth to participate in the 2020 Districts Youth Conference. (If you agree, please answer with your FULL NAME here. If you have any comments regarding this agreement & permission, please add them below. If you do not agree, please answer "do not agree" and explain in comment section below.)
IF you would like to make an ADDITIONAL DONATION towards students in financial need, fill in an amount below. Otherwise, leave blank!