Youth MINI RETREAT 2019JUNE 28-29 Youth MINI RETREAT 2019 Online Registration Agreement* PLEASE READ THIS AGREEMENT CAREFULLY AS USE OF THE SERVICE CONSTITUTES ACCEPTANCE OF THESE TERMS AND CONDITIONS. IF YOU DO NOT AGREE, DO NOT REGISTER. Online registration for this event may only be completed by an adult eighteen years old or older. The registration of a child under thirteen years old must be completed by that child's parent or legal guardian. I agree I do not agree Youth Name* First Last Child 1 Birthdate* Date Format: MM slash DD slash YYYY Child 1- Last grade completed*6th7th8th9thChild's Name-2 (Only if have more than one child to register) First Last Child 2 Birthdate (if applicable) Date Format: MM slash DD slash YYYY Child 2- Last grade complete6th7th8th9thParent/Guardian Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Primary Phone*Parent/Guardian Secondary PhoneParent/Guardian Email Allergies/Health information/Special NeedsPlease provide us the appropriate information. Leave blank if not applicable.Emergency Contact #1 First Last Emergency Contact #1 PhoneEmergency Contact #2 First Last Emergency Contact #2 PhoneMay we photograph your child? Images may be used in end of program video/on our church website.* Yes No If you are a member/regular attender at a different church, where at?