Youth Registration Form -Cabin Trip 2022
Youth Registration Form -Cabin Trip 2022
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Student Name
*
First
Last
Date of Birth
*
/
MM
/
DD
YYYY
Gender
*
Female
Male
Grade
*
Parents/Guardians' Name
*
First
Last
Home Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Home Phone
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(###)
-
###
####
Parents' Cell
*
-
(###)
-
###
####
Section Break
Insurance Carrier
Policy/ID#
*
Insurance Company Phone
*
-
(###)
-
###
####
Section Break
In Case of Emergency Contact:
*
First
Last
Emergency Contact Phone
*
-
(###)
-
###
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List of all current medication/dosage:
*
Any activities to be restricted:
*
HEALTH HISTORY: Does student have allergies, heart problems, asthma, blood disorders, past serious injuries, seizures, diabetes, past surgeries, chronic recurring illness, etc.? EXPLAIN.
*
Section Break
EMERGENCY AUTHORIZATION:
*
By checking this box give my child permission to attend Family of Christ's Cabin Trip, August 18th-20th. In the event that I cannnot be reached in an emergency, I hereby give permission for the leadership of my church personnel to have an authorized doctor or medical professional, hospitalize, administer medical aid and treatments, order injections, anasthesia or sergery for my child at any time they believe an emergency exists. I will be responsible for all medical bills. I agree not to hold Family of Christ or the leaders responsible for any accident should it occur.
*
Student will be participating fully in the entire retreat, including driving up and returning with the group to and from church
My youth has conflict/schedule adjustments and can only participate in part of the weekend