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Evangelical Bible Church
Dallas, Oregon
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Register
November 22
–
November 25
View Registration Form
Student's Name
*
Spaces
The number of spaces you wish to reserve.
Email
*
The email to associate with this registration.
Home Address
Address 1
*
Address 2
City
*
ZIP code
*
Primary Contact Name
*
Primary Phone Number
*
Secondary Contact Name
Secondary Phone Number
Dietary Restrictions
This student has allergies
Please Explain
This student has medical conditions
Please Explain
Name and dosage of medication (one per line please)
Health Insurance Name (Optional)
If you prefer, send a copy of your insurance card with your child.
Policy Group Number (Optional)
I agree to the following:
*
I the parent / guardian, give permission for this student, if necessary, to go to the nearest hospital/clinic and receive appropriate treatment as deemed necessary by the attending medical personnel. If medical attention is needed, every reasonable attempt will be made to notify me as soon as possible. I understand that Evangelical Bible Church is not responsible for the cost of medical care provided to my child. I assume responsibility for the transportation of my son/daughter in the case of any non-related emergency situation that results in an early dismissal. My son/daughter has permission to attend this retreat and participate in all activities.
How Do You Want to Pay?
*
Online
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In person
Note:
You can make an online
payment here
.
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Friday, November 22,
–
Monday, November 25, 2024
6:30pm
–
1:00pm