2010 Youth Convention

2010 YOUTH & YOUNG ADULT CONVENTION

Early Bird PRE-REGISTRATION

$20.00 per person

(Registration after May 31 - $30)

PERSONAL INFORMATION
Name *
Address *
City *
State
Zip Code *
Phone *
E-mail
Sex *	M F
Birthdate *
Age: *
Name as you would like to appear on Name Badge: *
Church Name *
Church Address *
City *
State
Zip Code
EMERGENCY CONTACT FOR AUGUST 5-7 (THURSDAY - SATURDAY)
Name *
City
State
Day Phone *
Evening Phone *
Other
INSURANCE/MEDICAL
Do you presently have health insurance?	Yes No
Health Insurance Carrier
Phone
Address
Policy#
Group#
Subscribers Name (Primary Insured)
Please describe any pre-existing conditions you may have:
Please list any food or drug allergies you may have:
Please list any medications you take regularly:
GRADUATES ONLY
School Name
City
School	Middle School High School College
Type of Degree
Special Honors
If you are registering more than one person for the convention, please email the following information for each person registering to sofyaya2010@yahoo.com. Name Address Phone number Age How name is to appear on badge Church Name Scholastic Achievements Emergency contact name Emergency contact number

I accept

NOT JUST A FELLOWSHIP...BUT A RELATIONSHIP!!!