Registration Form


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We are going to

@Web from 12-7am

Sponsored by The Heritage YouthNation

Date: Saturday, Dec. 29 at 9:15pm

ending on Sunday,

Dec. 30 at 8:15am.

All students will gather at Center for registration before departing for THE WEB in West Chester, OH (N. Cincy)

COST: only $25.00

(includes transportation, All the Laser Tag, Mini-Bowling, Putt-Putt, Go Carts & Food!)

INVITE YOUR FRIENDS!!! INVITE YOUR FRIENDS!!! INVITE YOUR FRIENDS!!! INVITE YOUR FRIENDS!!! INVITE YOUR FRIENDS!!!

Make sure you register by Sunday, December 23rd. **all registrations received after 12/23will be $30.00 (Limited to 80 registrations)

Pick up Registration Form at YouthNation or online at www.heritagewch.com THE WEB - the tri-state's newest and most exciting entertainment center! All-Niter includes: LASER WEB: largest multilevel laser tag arena - HANG 10: miniature bowling alley JURASSIC PAR: 9-hole black light mini-golf GO-CART TRACK: Cincinnati's only electric go kart track Arcade and Prize Center FOOD

*NEW THIS YEAR—PIZZA BUFFET(2-4am)/FREE VIDEO GAMES(1hr) Digital Climbing Wall - - - - - - - - - - - -  - - - - - -  - - - - - -  - - - - - -  - - - - - - -  - - - - - - -  - - - - - - -  - - - - - - - -  - - - - - - -  - - - - - -

YOUTH EVENT PARENTAL PERMISSION FORM Event you are attending: THE WEB All-Niter

THYN The Heritage YouthNation

Name ______________________________________________________ Address ____________________________________________________ City/State/Zip ______________________________________________ Phone _______________________________ Grade ____________ Birth Date _______________________________ Emergency Phone _________________________________ (REQUIRED)

We are most appreciative of your trust in us, as we undertake to minister to your teen. For reasons that are apparent, we are requesting that you sign this Release of Liability and Consent for Medical Treatment Form to allow us to have your child participate in the activities specified. Thank you for your cooperation, and please know that we take our responsibilities most seriously.

I hereby release and hold harmless from liability Heritage Memorial, Washington Court House ,Ohio, it's staff members, volunteer workers, and other employees and/or agents in the event of any injury to my teen not resulting from the negligence of any such staff, volunteers, employees and/or agents while my teen is engaging in any church activity. I further consent to any hospital or medical care necessary for my teen, and such medical care may be approved by my teens leader/director and physicians immediately employed in any medical facility where they may be treated, including all emergency treatments which in the judgment of said physicians may be considered necessary or advisable for my teen. Ii

I understand that this is a legally binding release and consent. I have carefully read this Release of Liability and Consent for Medical Treatment Form and fully understand its contents. Being aware of said contents I sign of my own free will. Medical concerns___________________________________________________________ __________________________________________________________________________ __________________________________________________________________ Parents signature Date Student may be given: __________________________________________________________________ Insurance Company Policy #

 Tylenol  Benadryl  Pepto-Bismol  Ibuprofen  Other:________________ Allergies: _________________________________________________________________