IGNITE YOUTH CONFERENCE in Des Moines, Iowa
FBC 8th Grade & High School Youth Event
Youth First Name
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Youth Last Name
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Birthdate
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Boy
Girl
Cost per student: $90
Parent/Caregiver Name
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Street Address
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City
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Zipcode
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Phone Number
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Email Address
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Emergency Contact if parent can't be reached - Name, Relationship, Phone)
Hospital
Medical Insurance & Policy Number
Should your child need medical attention, list any instructions that might be helpful to a physician such as blood type, allergies, or other medical concerns.
Date of last tenanus vaccine
Do you have a home church?
Yes
No
If yes, church name:
RELEASE: I hereby release and agree to hold harmless First Baptist Church of Champaign at Savoy (FBC-CS) and designated leaders from all liability for damage, illness, or injury. In case of emergency, I give my permission for any necessary medical treatment. I will not hold FBC-CS or any leader/staff persons responsible for any injury that may occur.
I also give my permission to FBC-CS to use photos of my children, without any identification, in publications and/or on their websites for promotional purposes.
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Yes, I agree
Please verify your information above. Submit button will take you to Paypal for payment.
Registration is not complete until payment is received.
Security Code
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