Participant Info

First Name*

Last Name*

Preferred Badge Name*

Address*

Town / City*

State*

Postcode / Zip*

Gender*

Male

Female

Age as of 4/1/19*

Grade as of 4/1/19*

Parish Name & City

Parent/Guardian Info

Parent/Guardian*

Parent/Guardian Email (For confirmation)*

Emergency Phone

Will parent/guardian be present at convention?*

Yes

If parent/guardian will not be at convention, who will be the adult attending convention that your child will be staying with (if not in Youth Rally lodging)?

Full Weekend Registration

(Skip to next section if registering for specific days)

Registration Selection

Youth Rally Gr 5-12 $110

VBS Gr K-4 $70

YOUTH RALLY Lodging Selection (VBS stays with parent)

With youth lodging

With parent lodging

Partial Weekend Registration

Additional Questions

Youth Rally Only: T-shirt size

Do you want to add Friday lunch for $10?*

Yes

Health Form

If your child has allergies or is currently taking any medications, please list below. If non, write NONE*

Explain any physical restrictions or any health/behavioral concerns we should be aware of. If none, write NONE*

Please list insurance company, policy #, name of insured and relationship to child.

Permission to provide treatment or emergency care The information provided above is correct. The person herein has permission to engage in all activities except noted by me. In the event that I cannot be reached in an emergency, I hereby give permission to the health care provider selected by a diocesan representative to secure proper treatment, order injections and/or anesthesia and/or surgery, and hospitalize my child named above. I give permission for my child to appear in photographs, video, and social media that may be used to promote Beaver Cross Camps and Beaver Cross Ministries. Enter your electronic signature:

Fees will be calculated on the next page when you hit SEND. Only pre-paid registrations will be accepted and are due by May 31, 2019.

Episcopal Diocese of Albany

Disciples Making Disciples

Youth Rally & VBS Registration

Participant Info

Parent/Guardian Info

Full Weekend Registration

Partial Weekend Registration

Additional Questions

Health Form

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