Event Registration

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Heart Youth Fall Camp on Friday, August 30, 2019 @ 5:00 PM

119.00
*One child per form please. If you have an additional student(s) to register, complete the form, click "Next", then click Register Another Person. --- NO REFUNDS or EXCHANGES
If you choose cash or check option, payment must be brought into the church office or turned into a leader within 10 days of registration or your spot will be opened up for another student.
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*Student's Birthdate:
*Parent(s)/Guardian(s) Name:
*Parent(s)/Guardian(s) Phone Number:
*Parent(s)/Guardian(s) Email:
*T-shirt Size (Adult Sizes):
Were you invited by a friend? If so, who?:
Are there any food allergies or special needs we should be aware of?:
Photo Release: I hereby consent, on my own behalf and/or my minor child's behalf, to allow Pure Heart Church, and any person acting under its authority, permission to photograph and/or record me and/or my child. I give consent for Pure Heart Church to use the material for broadcast, internet streaming, social media and/or promotional materials.
*Photo Consent:
Permission to attend Pure Heart Church's Fall Camp at AZ Elks Camp in Globe, AZ
By my electronic signature below I give my child permission to participate in the above-mentioned event. In the event that he or she is injured while participating, I do hereby authorize and consent  to any x-ray, examination, anesthetic, medical, or surgical diagnosis rendered under general or special supervision of any licensed medical staff member under the provisions of the Medicine Practice Act. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, but is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment, may deem advisable. It is understood that effort shall be made to contact me, the undersigned, prior to rendering treatment to my child, but that any of the above treatment will not be withheld if I cannot be reached. I also agree to accept all responsibility for the cost of the above-mentioned medical services. I understand the nature of this event and do hereby release Pure Heart Church, or any of its representatives from any liability for accidents or injury sustained by my child in conjunction with this event. 
*Parent/Guardian Signature (First and Last Name):
*I am:
If you checked "other" what is your relation to the student?:
*Date signed:
**Register by August 4th to receive early bird discount of $20.00!**Enter code: earlyfall20
If you chose the Cash/Check option, do not enter code here