Jesus journey 2017

$35 Registration fee can be paid beforehand or sent with youth on the weekend of JJ

Participant Name *
Participant Name
T-shirt size *
Allergies / Restrictions
Is the participant listed above allergic to any medications, foods, environmental, or other substances? *
Is your child currently on any medications? *
Emergency Contacts
Please list phone numbers in the order we should call.
INFORMED CONSENT & AUTHORIZATION for EMERGENCY TREATMENT and TRANSPORTATION Section
1. I understand that I will be notified if the participant listed on this form, becomes injured and/or ill while attending Jesus Journey.
2. In case of an emergency or when I cannot be reached, I hereby give authorization to contact other emergency contact people listed on this form. If no one listed on this form can be reached, then I hereby give authorization to the FBC Youth Leaders and the treating physician to obtain or provide whatever medical treatment and/or transportation deemed necessary for the immediate welfare of the participant, listed above.
Condition of Registration:
I have read, understand and agree to the terms and conditions listed on this Emergency Contact Form and I understand it is my responsibility to provide accident and health insurance coverage for listed participant and I will be financially responsible for all charges and fees for emergency medical treatment and/or transportation, regardless of whether my medical insurance covers such charges and fees.