Advance 2018 : Friday, July 13th to Monday, July 16th

Payment of $175 is due by Friday, June 1st. Form must be complete before payment may be received.
Please enter a new registration for each student.
Begin Registration
 
Student's first & last name

*

 
{{answer_x65SD9rVJsaN}}'s date of birth *

Month Day, Year
 
HOME ADDRESS

 
{{answer_x65SD9rVJsaN}}'s street address *

Example: 676 Lincoln Hwy
 
{{answer_x65SD9rVJsaN}}'s city *

Example: Fairless Hills
 
{{answer_x65SD9rVJsaN}}'s state *

Example: PA
 
{{answer_x65SD9rVJsaN}}'s zip code *

Example: 19030
 
{{answer_x65SD9rVJsaN}}'s cell phone number (optional)

xxx-xxx-xxxx
 
Home phone number *

xxx-xx-xxxx
 
We (Remnant Youth Ministry) will make every effort to provide safe conditions with adequate adult supervision. We are always interested in providing a safe event in every way and in the spiritual, physical, and mental development of {{answer_x65SD9rVJsaN}} 

To help us do so, please provide the information requested in the next few questions.
 
ALLERGIES, MEDICAL, BEHAVORIAL INFORMATION

 
List any allergies or conditions that may be relevant to a physician in the event of an emergency (please include any previous injuries). *

If student has no allergies please type "NONE"
 
Please list any medication(s) {{answer_x65SD9rVJsaN}} is currently taking. *

If student is not taking any medication(s), please type "NONE".
 
Please list any medical/behavioral concerns or limitations the leadership team should be aware of. *

If there are no concerns, then please type "NONE"
 
MEDICAL INSURANCE

 
Do you have medical insurance? *

     
 
Medical Insurance Company name *

If you do not have medicial insurance, please type "N/A"
 
Policy Number *

If you do not have medical insurance, please type "N/A"
 
Please indicate if the ministry staff/leaders/volunteers have permission to administer over-the-counter (OTC) medications such as Ibuprofen (ie Advil, Motrin), Acetaminophen (ie Tylenol), Antacid (ie Tums), Antihistamine (ie Benadryl), Cough Drops, etc. to {{answer_x65SD9rVJsaN}} *

     
 
EMERGENCY CONTACT #1

Information for an Authorized/Designated Individual to make emergency decisions.  You will have the opportunity to enter an additional emergency contact.
 
Name of emergency contact #1 *

Provide the first and last name of authorized/designated emergency contact
 
Relationship to {{answer_x65SD9rVJsaN}} *

Example: parent, friend of family, aunt, grandparent, etc.
 
{{answer_xH7uQK0HoUsH}}'s phone number *

 
{{answer_xH7uQK0HoUsH}}'s home address *

 
EMERGENCY CONTACT #2 (Optional)

Information for an Authorized/Designated Individual to make emergency decisions.
 
Name of emergency contact (optional) *

Provide the first and last name of authorized/designated emergency contact.
 If you do not wish to add a 2nd emergency contact, please type "N/A"
 
Relationship to {{answer_x65SD9rVJsaN}} (optional) *

Example: parent, friend of family, aunt, grandparent, etc.
If you do not wish to add a 2nd emergency contact, please type "N/A"
 
{{answer_Zb05gThD3opF}}'s phone number (optional) *

If you do not wish to add a 2nd emergency contact, please type "N/A"
 
{{answer_Zb05gThD3opF}}'s home address (optional) *

If you do not wish to add a 2nd emergency contact, please type "N/A"
 
*RELEASE STATEMENT, ELECTRONIC SIGNATURE, CANCELLATION POLICY


*Please click "I agree" at the end of the statement

I, the parent/guardian, provide my electronic signature which indicates that, in the event of an emergency and in the event that (1) a parent/legal guardian or the Authorized/Designated Individual identified in this form cannot be reached; or (2) immediate medical attention is necessary, I consent to have the IFCA and/or Calvary Full Gospel Church staff/leaders/volunteers act in my behalf and I hereby grant my permission for emergency treatment to be administered to {{answer_x65SD9rVJsaN}} until a parent/legal guardian or Authorized/Designated Individual(s) identified in this form can be reached. I agree not to hold IFCA, Calvary Full Gospel Church, or any staff/leaders/volunteers, liable for decisions or any emergency medical treatment made under this authorization, for any accident or loss to the student however caused.

Cancellation Policy: If request for cancellation is received by the deposit due date your deposit will be refunded in full. If request is received after the deposit due date, your deposit is not refundable. If you cancel before the balance due date, you will receive your paid balance minus your deposit and any expenses incurred in the cancellation of trip arrangements already made on behalf of your student (e.g. tickets, etc…). If at time of cancellation, costs incurred exceed balance paid, you will be responsible to pay the difference. We are sorry, but no refunds can be processed after the balance due date as IFCA and/or Calvary Full Gospel Church must fulfill its contractual obligations with our partners. My signature indicates that I have read, and do agree to the conditions listed above, and that I have included any necessary information regarding {{answer_x65SD9rVJsaN}} 
 
Electronic Signature indicates you have read and agree to the statement above (release statement and cancellation policy) *

Please enter YOUR (the parent/guardian) first and last name
 
Today's date *

 
REMNANT RELATED ACTIVITIES

 
Does {{answer_x65SD9rVJsaN}} have your (parent/guardian) permission to participate in ALL Remnant related activities in the next year (July 2018 through June 2019)? *

If "no" is indicated, students can still participate. Permission will be requested separately for each event/activity.
     
 
Remnant Youth Ministry will be notified if there are any changes in emergency contact(s) or medical conditions from one event to another.

 
Please review the Advance 2018 rules & consequences listed in the next two sections.  Both parent/guardian and student MUST agree to abide by each statement.

 
ADVANCE 2018 RULES:

 
Rule 1 - Everyone must attend all services, sessions, and meals.
Rule 2 - No boys in girls' buildings/rooms.  No girls in boys' buildings/rooms.
Rule 3 - No pranks.
Rule 4 - Keep cell phones at home.**
Rule 5 - Keep all electronic devices at home (tablets, iPODs, etc.).
Rule 6 - No PDA (public displays of affection).
Rule 7 - No tobacco products, drugs, or alcohol.
Rule 8 - Respect leaders, volunteers, conference center staff, and each other.
Rule 9 - No one is allowed outside their rooms past curfew.
Rule 10 - Everyone must be dressed appropriately at all times.

** The youth leaders will have cell phones which students may use in case of emergency or to contact home.
 
ADVANCE 2018 CONSEQUENCES:

 
Consequence 1 - 1st rule violation: student will be given a verbal warning

Consequence 2 - 2nd rule violation: student will lose a privilege and will call home**

Consequence 3 - 3rd rule violation: student will call parent/guardian to come and pick him/her up


** If a cell phone is confiscated by a leader, it will count as two rule violations.  As noted above, bringing a cell phone is a violation of the Advance rules, which would warrant violation one.  Violation two would occur as a result of the willful dishonesty to Remnant Youth Ministry.
 
Your electronic signature indicates that you and {{answer_x65SD9rVJsaN}} have read, understand, and will abide by the rules and consequences. *

Provide your (the parent/guardian) first and last name which serves as your electronic signature.
 
PAYMENT OPTIONS: There are several options when it comes to paying for the Advance 2018 Retreat:

1. Cash

2. Check - Please make payable to Calvary Full Gospel

3. Online Payment - AFTER SUBMITTING THIS FORM Please visit calvaryfullgospel.org and click on Online Giving. Please indicate payment in Other Donation, and list reason as "Remnant - {{answer_x65SD9rVJsaN}}". See example below.
Thanks for completing this typeform
Now create your own — it's free, easy, & beautiful
Create a <strong>typeform</strong>
Powered by Typeform