|
Name: |
|
|
| Age: |
Birthdate:
|
Church: |
|
| Address: |
|
| Phone #: |
|
| E-mail: |
|
| Care Care #: |
|
Family Doctor: |
|
| Doctor's Phone #: |
|
|
|
| |
|
| Does you have any severe allergies?
(bee stings, food, penicillin, other drugs) |
Yes:
No:
|
| If Yes, please explain: |
|
| Are you bringing any medication with you? (Antibiotics, ventilator, Ritalin) |
Yes:
No:
|
| If Yes, please explain: |
|
| |
|
|
|
| PHOTGRAPH CONSENT |
|
|
I hereby consent for the above named child to be photographed by GLAD TIDINGS CHURCH VICTORIA. |
|
|
|
|
| Photographs may be used in publications produced by Glad Tidings Church Victoria. The publications may include, but are not limited to: brochures, bulletins, advertisements and websties. Children will not be identified by name. |
| |
|
|
|
I acknowledge that all of the above information is current and correct and I hereby give permission for my dependant to participate in the activities, programs and services of the Illuminate Conference being held at
Glad Tidings Church. |
| PARENT/LEGAL
GUARDIAN NAME:
|
DATE:
|
| |
|
|
|
ILLUMINATE CONFERENCE REGISTRATION COST:
Early Registration: $35.00
- Before February 1, 2010
Standard Registration: $45.00
- After February 1, 2010
Door Registration: $50.00
(* Receipt of payment confirms your spot at the conference.)
|
SEND REGISTRATION AND PAYMENT TO:
Illuminate
co/ Glad Tidings Church
1800 Quadra Street
Victoria, BC, V8T 4B9
Cheques Payable to:
Glad Tidings Church
|
|
| |
|
|
|
|
|
