Awaken '10 Registration Form.pdf

Awaken ’10
REGISTRATION FORM

Registrant’s  Name (use a separate form for each child)       
Address       
City, State, ZIP       
Phone   
Email for Registration Confirmation

Grade in 2010-2011     7      8      9     10     11     12  

Gender              M                 F   
Primary campus/site your family attends:    North     Downtown     South     Visitor   
If you’re a visitor, who do you know at Bethlehem that we can group you with?       
Which program(s) does your child regularly attend    Sunday School        Wed Connection     Both              Neither   
T-Shirt Size    YS      YM      YL      S      M      L      XL   
Best Contact Information for you this weekend:   

Price: $60 (checks payable to BBC) Paper forms will not be accepted after September 19. After event is full registrations will be placed on waiting list.

For information on scholarships or multiple family member discounts, please contact Kevin Dau at 612.455.3493 or kdau@usfamily.net. Enter Approved Scholarship or Multiple Family Member Discount Amount Here $__________

If you would like to use funds from your student account, please indicate the amount here $____________. To verify funds availability, contact Family Discipleship.

Figure Amount Due: $60 fee. Subtract any discount, scholarship, and/or student account money used.
Total Amount Due: $____________ (Make check payable for this amount)

Mail or deliver form to Kevin Dau at 720 13th Avenue South, Minneapolis, MN 55415 or fax to 612.338.6901.
Due to the complexities of this event, Paper Registrations received or mailed after September 19 will be rejected.

Parental Consent & Medical Treatment Form
Bethlehem Awaken ’10
I, the undersigned parent or guardian of the child listed below, who is a minor, do hereby authorize adult workers with the youth of Bethlehem Baptist Church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named below, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for rendering such service.

Furthermore, by registering my child, I consent to the use of any visual or audio media my child appears in for dissemination and distribution for purposes of archiving, keepsake, and promotion of Awaken '10.

Insurance Company   
Policy Number/ID/Group Number   
Print Name of Authorizing Parent   
Signature of Authorizing Parent

Medical Info
Medical Alerts, Other Allergies, Activity Restrictions (Give Details):
Primary Care Physician’s name and contact number:   
Emergency Contact Name and Number (other than parents):   

Thanks for registering for Awaken ’10! We look forward to seeing you there. May God bless this time pursuing Jesus with much fruit in your life!