Student Registration 2018

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Student Registration 2018 Friday May 4, 2018 @6pm – 9:30pm

Registration must be in by Apr. 18, 2018 if you would like a t-shirt (included) and/or sweatshirt ($25) Hurry! First Come, First Served! Space is Limited!

Please Note: FUEL is an event for 3rd, 4th, 5th, & 6th Graders

Please return this completed form along with your REGISTRATION FEE to your church leader(s).

REGISTRATION FEE: $30/Student Price includes t-shirt, SWAG bags, snacks, and more! Payment Method Cash

Check

Please make checks payable to JACOB’S WELL. Please write child’s name on memo line. Please return money and completed form to your church leader(s). NOTE: registration must be in by Apr. 18, 2018 if you would like a t-shirt (included) and/or sweatshirt ($25)

STUDENT INFORMATION PLEASE NOTE: FUEL IS AN EVENT FOR 3rd, 4th, 5th, & 6th GRADERS Full Name: Address/City/State/ZIP: Parent/Guardian Phone: Birthdate:

/

/

Email: Gender:

M

F

T-Shirt* (Adult Sizes Only | Included in Registration Fee): S M L XL Sweatshirt (Adult Sizes Only | Add $25): S M L XL

XXL XXL

*NOTE: registration must be in by Apr. 18, 2018 if you would like a t-shirt (included) and/or sweatshirt ($25)

MEDICAL INFORMATION Health Insurance Provider: Group Number:

Policy Number:

Any major medical concerns, allergies, or medications? PLEASE USE BACK OF THIS SHEET IF NEEDED

EMERGENCY CONTACT In the event that a parent cannot be reached in an emergency, please contact: Name:

Relationship:

Phone:

RELEASE

I give permission to my student,

STUDENT’S NAME

to attend FUEL at Jacob’s Well Church in Chippewa Falls, WI on May 4, 2018. In case of an emergency where medical treatment is required for my student, I give permission to the volunteer staff, or other chaperones/counselors in charge, to obtain medical treatment. Please attempt to notify me in the event of an emergency. I also understand that attendance to this event grants permission for registrants to be filmed, photographed, audio taped, etc and grants FUEL permission for full use of their likenesses and words without compensation.

PARENT SIGNATURE

PARENT PHONE