Districts

Blue

Leader Registration $70 

First Name:*
Last Name:*
Gender:
If you need help with payment, then how much of the $70 can you pay?
Address:
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Email:
Cell Phone:
Other Phone:
I would like to lead students in: *
Would you like to purchase a Districts T-shirt?
Health Concerns/Allergies/Limitations:
Current Medications:
Insurance Carrier:
Policy Number:
Emergency Contact:
First Name
Middle
Last Name
Emergency Contact Phone Number:
I do hereby release, forever discharge and agree to hold harmless Bethany Evangelical Free Church and it’s directors as well as the Forest Lakes District of the Evangelical Free Church of America and its leaders from any and all liability, claims or demands for personal injury, sickness, death, personal theft, damage and expense as a result of my participating in the 2019 Districts Youth Conference. I also authorize the 2019 Districts Leadership Team and volunteer Medical Staff to secure necessary emergency medical treatment for me in the event of injury while on this trip. We take photographs and video of conference activities. These pictures may be used for presentation during the conference, in our promotional materials, or on our website. If photographs are used on the website, they will not include any names. I give my permission to be photographed and videotaped.
Digital Signature:*
Signature Date:*