Student Registration $140 per person

Please submit payment to Bethany Church as soon as possible to complete the registration. If you need help with the cost let us know.
First Name:*
Last Name:*
Gender: *
Grade: *
Student Email (if any):
Student Cell phone (if any):
I request to room with (2 friends):
Would you like to purchase a Districts T-shirt?
Student Health Info
Pertinent Past Medical History:
Current Medications:
Dose/Frequency:
Allergies:
Type of Reaction:
Insurance Carrier:
Group/ID Number:
Parent Info:
Parent/Guardian Name:
First Name
Middle
Last Name
Student Address:
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Do you live at this address with the student?*
Parent Email
In Case of Emergency
Emergency Contact Name:*
Emergency Home Phone Number:
Emergency Cell Phone Number:
Emergency Work Phone:
Billy Hestand will have all the leaders contact info. His number is 608-399-5074.
I understand that direct supervision of my teen by the Forest Lakes District will be limited by the nature of the activity. I understand the risks involved, and I absolve the Forest Lakes District of the Evangelical Free Church of America and its leaders and the 2019 Districts Leadership Team from liability to me or my teen because of injury, accident, or illness while attending the 2019 Districts Youth Conference. I also authorize the 2019 "Districts" Leadership Team and volunteer Medical Staff to secure necessary emergency medical treatment for my teen 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 for my child to be photographed and videotaped. I agree to all of the above & give my teen permission to participate in the 2019 Districts Youth Conference.
Parent/Guardian Digital Signature:*
Parent/Guardian Signature Date:
Please submit payment to Bethany Church as soon as possible to complete the registration.