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Registration
First Name:
Last Name:
Parent Name:
Contact Number:
Email:
Address Line 1:
Address Line 2:
City:
State/Province:
Country:
Zip/Postal Code:
Name of Event You Are Planning to Attend:
Youth Beach Trip
Centri-Kid - Toccoa Falls
Children's T-Days
Other
Physician Phone:
Insurance Card Number:
Card Expiration Date:
Medical Conditions or Allergies:
Please make special note of food allergies.
Medications Currently Being Taken:
Please note medication name and times taken.
Terms of Agreement for Parents:
I (we) the parent(s) of the student named above hereby give my (our) permission for the named student to participate in the above named event with the leaders of NGBC. I (we)understand that in the event of an emergency, the leaders of NGBC will do everything in their power to contact me personally, but in the event that they are unable to do so, I (we) give permission for the leaders to seek necessary medical attention for the student named above.
Agreement:
select one
I (we) agree
I (we) do not agree
Terms of Agreement for Participant:
I promise to abide by all the rules set forth by the leaders of NGBC during the course of this event.
Agreement:
select one
I agree
I do not agree
Finanical Considerations:
We try and consider that finances may be difficult and sometimes have scholarship. By indicating your level of need in this box, you are applying and realize that there may be none available. Once you apply, we will determine how we may help. Whether its scholarship or a payment plan.
Other Comments, Questions, or Concerns:
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