I am RSVPing for
Please choose all that apply:
Middle School Ski Retreat
Senior High Ski Retreat
Middle School Service Week
MAD (music/arts/drama) Camp
Senior High Belize Mission
Middle School CROSS Mission Trip
Montreat Youth Conference
Your information
Your name
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Your e-mail address
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Street address
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City/state/ZIP
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Birthday (MM/DD/YY)
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School grade
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School
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Home church
Parents' names
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Parents' phones
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Emergency contact
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Emergency contact phones
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Who may pick you up other than parents?
Medical release information
This form gives the group leader(s) authorization to secure medical aid for your youth should it be necessary.
Medical insurance company
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Medical insurance policy number
Other insurance information
Physician's name and phone
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Other pertinent health information such as allergies
Authorization
I authorize a representative of First Presbyterian Church to acquire medical care and/or treatment on my behalf if I cannot be reached by telephone or there is not time or opportunity to make a telephone call. I agree not to hold First Presbyterian Church or its representative responsible for any damages arising from this consent. I understand that First Presbyterian Church occasionally takes photos of events for use in promoting the church’s ministries.
Parent name
*
Today's date
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Security Code
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