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Excel Ministries - Jr. High & High School
Excel Forms and Registrations
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Excel Forms and Registrations

Excel Winter Retreat 2012

To register, please fill out the form below and follow prompts for making payments.

Student's Last Name *
Student's First Name *
Student's Cell Phone *
Student's Email Address *
Re-enter Student's Email address (for confirmation) *
Gender *
Parents' Names *
Parents' Home Phone *
Parents' Cell Phone *
Parents' Email *
Re-enter Parents' Email address (for confirmation) *
Emergency Phone *
If same as any number, please re-enter
Address *
Apartment or Unit #
City *
State *
Zip Code *
Date of Birth *
mm/dd/yy
Grade/staff *
                
School Attending *
Invited by
Allergies (drug & environmental)
Medications
Health History (please check all that apply) *














Other
Health Insurance Company *
Insurance Group # *
Insurance Policy ID # *
Policy Holder's Name *
Student's Primary Physician's Name *
Student's Physician's Phone Number *
I hereby authorize the participation of the above named individual in activites at Camelback Bible Church. In consideration of Camelback Bible Church providing these activities, I do hereby release Camelback Bible Church, its officers, employees, agents, and members of the Board of Elders from all claims and causes of action by reason of any injury which may be sustained as a result of these activities whether on the church premises or on the way to and from these activities.  I agree to cooperate and conform with the directions and instructions of the personnel of the organization in charge of these activities.  I hereby give my permission to the physician, nurse or dentist selected by Camelback Bible Church to secure medical or dental aid as required for illness or injury under a physician's orders including transportation to and from the necessary facilities.  As a participant I understand that Camelback Bible Church is not obligated to carry any insurance to cover those medical and or dental expenses.  If such insurance is carried, coverage will only be provided for expenses in excess of the limits of the participant's insurance as my primary coverage.
I agree *
Payment *
    
Extras *
      




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