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Junior High Encounter
Sunday, November 16th | 1 – 8pm
Registration
Registration
How many students are you registering?
*
Please enter a number from
1
to
3
.
Student #1 Name
*
First
Last
Student #1 Grade
*
Select
6th Grade
7th Grade
8th Grade
Student #1 allergies?
*
Yes
No
List allergies here:
*
Student #2 Name
*
First
Last
Student #2 Grade
*
Select
6th Grade
7th Grade
8th Grade
Student #2 allergies?
*
Yes
No
List allergies here:
*
Student #3 Name
*
First
Last
Student #3 Grade
*
Select
6th Grade
7th Grade
8th 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:
*
MM slash DD slash YYYY
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
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