Junior High Encounter

How many students are you registering?*

Please enter a number from 1 to 3.

Student #1 Name*

First Last

Student #1 Grade*

Student #1 allergies?*

Yes
No

List allergies here:*

Student #2 Name*

First Last

Student #2 Grade*

Student #2 allergies?*

Yes
No

List allergies here:*

Student #3 Name*

First Last

Student #3 Grade*

Student #3 allergies?*

Yes
No

List allergies here:*

Parent Name*

First Last

Parent Cell Phone*

Parent Email Address*

Email List

Subscribe me to the Cypress Creek Student Newsletter
Subscribe me to the Cypress Weekly, if I'm not already!

Do we have permission to take photos of your child(ren)?*

Yes
No

Emergency Contact*

Name:	Phone Number:

Insurance*

Insurance Company:	Policy Number:

I, the undersigned, hereby release Cypress Creek Church, it's agents, employees, officers and servants, from any and all damages and injuries which may occur while (I/ my child) is participating in any/all Cypress Creek Church activities, on or off the premises. I also give my permission for Cypress Creek Church leadership to seek medical attention by a licensed physician in the event of a medical emergency. I certify that I have the legal authority to execute this release on behalf of (myself/ my child). I also agree, by signing below, that the above information is true and correct to the best of my knowledge.

Participant or Parent/Guardian Signature (if under 18 yrs. old):*

Today's Date:*

Shirt Size(s) for Student(s)*

Payment Method ($35)*

Pay with Check/Cash at the Door
Pay with Credit Card

Junior High Encounter

Credit Card*

Card Details

Cardholder Name

Address*

Street Address City State / Province / Region ZIP / Postal Code

Total

$0.00

Registration