2010 Youth Convention

2010 YOUTH & YOUNG ADULT CONVENTION

Early Bird PRE-REGISTRATION

$20.00 per person

(Registration after April 11 - $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

Name *
Address *
City *
State
Zip Code *
Phone *
E-mail *
Sex: *
Birthdate *
Age: *
Name as you would like to appear on Name Badge: *
Church Name *
Church Address *
City *
State
Zip Code
Name *
City
State
Day Phone *
Evening Phone *
Other
Do you presently have health insurance?
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:
School Name
City
School
Type of Degree
Special Honors

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