DNOW 2017 REGISTRATION
 
DNOW 2017 REGISTRATION
PARTICIPANT INFORMATION
Participant Last Name, First Name  * 
Address, City, State, Zip  * 
Phone (including area code) AND Email address  * 
Current Grade  * 
ADULT T-SHIRT (Women's Cut)
ADULT T-SHIRT
Medications:
List Allergies:
PARENT / GUARDIAN INFORMATION
Parent / Guardian Name  * 
Address, City, State, Zip (if different from above)
Daytime Phone / Evening Phone / Cell Phone AND Email address  * 
Insurance Company and Policy Number
EMERGENCY CONTACT INFORMATION (if parent/guardian cannot be reached)
Emergency Contact Last Name, First Name
Emergency Contact's Phone Number, including area code  * 
PARTICIPANT COST = $55(After October 1st = $65)
MEDICAL RELEASE & ACTIVITY WAIVER
In the event of an emergency, I hereby give permission to the church-appointed sponsors who are with my child at the event named below to obtain medical assistance for my child.
I also give permission to the physician selected to hospitalize and secure proper treatment for my child:
Sponsor: CENTRAL VALLEY BAPTIST CHURCH 600 N. Ten Mile Rd., Meridian, ID 83642
Activity: DISCIPLE NOW WEEKEND November 3 - 5, 2017
In consideration of the permission granted to the participant named above, by the above names SPONSOR/CHURCH to participate in the above described ACTIVITIES, I hereby release said
SPONSOR/CHURCH, its agents and employees, from all actions, causes of action, damages, claims, or demand which I, my heirs, executors, administrators, or assigns may have against
said SPONSOR/CHURCH, THEIR AGENTS AND EMPLOYEES, and other above described parties for all personal injuries known or unknown which the participant named above, has or may incur by
participating in the above described ACTIVITY. I, the undersigned, have read and understand all its terms. I execute it voluntarily and with full knowledge of its significance.
By entering your name you are agreeing with this Medical Release & Activity Waiver.  * 
Your Email Address  * 
Please type in the box to the right »  * 
Total $
 
 
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