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“The Call” High School Youth Conference
“The Call” High School Youth Conference
Noor Atisha
2024-03-12T17:07:01-04:00
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Current Grade Level
(Required)
9th Grade
10th Grade
11th Grade
12th Grade
Gender
(Required)
Male
Female
Which youth group do you attend, if any?
(Required)
CLC St. Joseph
DOC
.CoM
CLC St. Thomas
MRUs
Super Saints
Other youth groups
None
If other youth group please put below which group(s) you are involved in
(Required)
Please describe any allergies (if none please type in none)
(Required)
Do you need transportation to and from the camp?
(Required)
Yes
No
Parent Name
(Required)
First
Last
Parent Phone
(Required)
Parent Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Liability Release Form
I give permission to my named son/daughter to attend ECRC’s "The Call" High School Youth Conference. If needed for health reasons, I give permission for my child to be evaluated, treated, and/or given over-the-counter medication in accordance with standard medical practice by appropriate health care personnel. I give my permission to ECRC and its agents to share and disclose health and medical information for the treatment and care of my child and to disclose this information to Chaperones who are responsible for my child. I release ECRC and its agents of all responsibility and consequences that may arise as a result of any injury suffered and resulting treatment. Further, I agree to accept any and all financial responsibility as a result of scheduling medical treatment. My child agrees to abide by all the rules and regulations stated by ECRC and the conference staff. I understand that ECRC will not be liable if my child fails to cooperate with regulations, and that any infraction of the rules may result in immediate dismissal from the conference at my expense.
Parent Signature (Type your name below)
(Required)
First
Last
Date of Signature
(Required)
MM slash DD slash YYYY
Cost Per Person (Includes lodging and all meals)
Price:
If you would like to help pay for the 3.5% credit card processing fees please click YES below
YES
CC Processing Fees
Price:
$0.00
Total
Credit Card
(Required)
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
Month
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
Year
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
Security Code
Cardholder Name
Δ
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