Confirmation Refresh Portions of this form should be completed by a parent or guardian for attendees under 18. Guests are asked to secure their own housing arrangements. You will receive a confirmation email when you successfully submit your registration. If you do not receive this email please contact events@flbc.edu. Name(Required) First Last Biological Sex(Required) Male Female I Am Registering As(Required) Student Adult LeaderParent, Pastor, Youth Leader, or other adult participating in the event. Days Attending(Required) Friday and Saturday ($25) Friday Only ($10) Saturday Only ($20) Grade(Required)5th6th7th8th9thAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail(Required) Home Congregation(Required)Church name, City, StateMedia Release - Filled out by parent if under 18 I consent for my child to appear in photos or video footage of this event that may be used in FLBC promotional materials. If I am 18 years of age or older, I give my own consent. Communication Preferences - I would like to receive updates about future events and additional resources from Free Lutheran Bible College AFLC Youth Ministries Medical Release Form- To be filled out by parent if attendee is under 18 years of age, or by attendee if over 18.Parent or Legal Guardian Emergency Contact - Name(Required)Parent or Legal Guardian Emergency Contact - Mobile Phone(Required)Instructions: Read while filling in all required information and give full initials for each entry. Each field requires a response. Any documents with incomplete or incorrect initials, Parent/Guardian Name or Dates will be considered void. Activities: General on campus recreation. Sports and other physical activities in the Student Life Center gymnasium. I consent to my child participating in the above named activities. If I am 18 or over, I am signing this assumption of risk.Initials(Required)Below are allergies or medical conditions that may be relevant to the FLBC kitchen staff in meal prep or a physician in the event of an emergency:Initials(Required)I will not/ I do not want my child to engage in the following activities:Initials(Required)I authorize FLBC staff who are in charge of any specific activity to make emergency medical decisions for my child in the event I cannot be reached. I will immediately notify the person in charge of any activity of any change in the information presented here. I agree that this Assumption of Risk shall be valid until I revoke it. I have signed this Assumption of Risk both in my own capacity as a parent/guardian of my child and in a representative capacity on behalf of my minor child. I represent and warrant to FLBC that I/each of us have/has completed this Assumption of risk form for my child to participate in this activity; that it is complete and correct in all its information; that I / each of us have/has inserted my/our initials beside each completed item; and that I/we have dated the form and typed my/our name(s) below to represent to FLBC my /our intent to be fully bound in accordance with its terms.SignaturesFull Name of Parent/Guardian (or attendee if over 18)(Required)Date(Required) MM slash DD slash YYYY PaymentTotal Payment(Required) I will pay online I/my church will pay at the event Credit Card Δ
