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Event Registration
Event
*
April 27th ALL NIGHTER $30
July 23rd North Texas AG Youth Camp $250
Student Name
*
T-Shirt Size ($10)
Parent or Legal Guardian's Name
*
Student Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Home Phone
*
Student Cell Phone
Student Email Address
School They Attend
Lunch Schedule
Grade
Male or Female
*
F
Male
Female
Age
*
Date of Birth
*
Do you have any medical problems or allergic reactions to any medications?
*
LIMITATIONS
Does this student have any physical limitations?
*
Yes
No
Has this student had psychiatric treatment?
*
Yes
No
Does this camper have mental limitations?
*
Yes
No
If Yes, Please explain:
*
Make all checks payable to Family Cathedral of Praise or FCOP. Credit Card Information must be correct and good to process registration form.
Name on Card
First
Last
Address on Billing Statement
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Credit Card #
CC Exp Date (##/##)
CC Sec. Code
I affirm that all information above is real and factual
*
Yes
No
Minor’s release of claims and hold harmless agreement I, hereby affirm and agree that I am he parent or legal guardian of the child listed above, a minor (“Minor”); that I am legally competent to sign this agreement and release; that I have fully informed myself of this agreement by reading it before signing; and that I have fully informed myself of the details and risks of the Activity prior to signing this release. I agree, individually and on behalf of Minor, to release and to hold harmless Family Cathedral of Praise and Asylum, its agents, officers, directors, and employees (collectively referred to as “the Church”) from liability of any kind, for Minor’s injury, death, or damage to or loss of Minor’s personal property, resulting directly or indirectly from his/her participation in the activity or from the Church’s negligence. I personally assume all risks and liabilities in connection with Minor’s participation in the Activity and agree to indemnify the Church from any liability assessed against the Church as a direct or indirect result of Minor’s participation in the Activity. This release includes all risks and liabilities connected with the Activity, whether foreseen or unforeseen. In the event that Minor is injured during the Activity, and I am unable to provide consent to his or her medical treatment, I authorize the Church to consent on my behalf to the performance of any and all medical treatment judged necessary by the Church, until I am able to provide consent or until some legally able to speak on Minor’s behalf is made available. I agree, individually and on behalf of Minor, to release, indemnify, and hold the Church harmless from any liability which may be assessed against the Church as a direct or indirect result of said medical treatment. I agree to pay or arrange for payment for all costs associated with said medical treatment. By clicking submit, I affirm that all information above is real and factual
I agree to the Minor's release of claims and hold harmless agreement.
*
I agree
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