First Name
Last Name
Address
City
State
Zip
Daytime Ph#
Youth Advance 2019 Registration
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Age
Email
School
Grade
Church/Org. Affiliation
Church/Org. Leader
Church/Org. Address
City
State
Zip
Does your child have any past medical conditions? Please list them.
This retreat is for middle and high school students only.
In Case of Emergency, Please Notify:
Phone 1
Date of last health exam
Insurance Provider
Policy/Group #
Have you ever been hospitalized in the last five years?

Parent/Guardian Consent
Parent(s)/Guardian(s) Information
First Name
Please list any known allergies.
Is your child on any type of medications? If so, please list the name(s) and prescribed dosages.
Last Name
Policy Holder
Address
City
State
Zip
Phone
First Name
Last Name
Address
City
State
Zip
Physician's Name
Phone 2
Phone 3
I hereby allow                                                                            to attend and participate in Saturate Me 2K19 Youth Advance.  In case of emergency, I understand that every effort will be made to contact me.  If I cannot be reached, I hereby give permission to the physician selected by the Camp Captains to hospitalize and secure proper treatment (including injection of anesthesia and/or surgery) for the teen named above.

I hereby acknowledge the risk involved in allowing my child to participate.  Therefore, I hereby waive, release, indemnify, absolve, and hold harmless Impacting Your World Christian Center, B.L.A.Z.E. Teen Ministry, it's staff and volunteers from any claim arising out of injury to my child.  I further waive for myself and my child the right to sue any of the above specified parties for any injury to my child.
Parent/Guardian Electronic Signature
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