2012 ELCA National Youth Gathering Registration

    New Orleans, LA - July 17-24, 2012

     

    Please complete the registration below. Your registration will not be complete until we receive your $150 non-refundable deposit.  After you submit this registration you will have the option to pay online, or you may send your payment to the Youth Ministry office at Word of Peace.

     

    * Required

     

    *Name (youth participant):

    *Age as of July 17th 2012: 

    *Grade Fall of 2012:

    *Event:

    *Date of Event:

    *Mailing Address  

    Home Phone Participant Cell Phone          

    *Parent Name

    *Parent Cell Phone

    *Parent E-mail Address

    (Parent email will be the main form of communication for Youth Gathering Information.  Your email will not be given out or used for other purposes.)


    Medical Information

    My son/daughter is in good physical condition and has not had any serious illnesses or surgery since his/her last medical examination.

    If no, please list illnesses:

    Allergies:

    Medications:

    Special Concerns:

     

    1st Emergency Contact:

    *Name:

    *Phone Number:

    *Relation:

     

    2nd Emergency Contact:

    *Name:

    *Phone number:

    *Relation:

     

    *Insurance Company:

    *Insurance Policy Number:

    *Primary Physician’s name:  

    *Clinic:

    *Clinic Phone Number:

     

    Permission for Event: 

    I give my son/daughter permission to participate in this event. I give my permission for any necessary medical treatment and I release Word of Peace Lutheran Church, the staff, and event adult leaders of any responsibility in the event of a medical emergency.

     

    Picture Use Authorization


    Word of Peace does not profit from the use of pictures or video and they are only used to show how we practice God’s faith. We will never post personal information such as last names or addresses of anyone. 

    I authorize Word of Peace Lutheran Church to take, modify, and post my picture and/or my family members' picture or other likeness on the Word of Peace website or in publications created and disseminated by Word of Peace.

    After clicking the Submit Form button below, you will be directed to the Word of Peace Direct Giving page for payment. Below are instructions to guide you through online payment process. If you do not wish to pay for this event online, simply leave the Direct Giving Page and send your payment to the Youth Ministry office. Please note that your registration will not be complete until payment is received. Thank you.

    1. Log in to your Direct Giving account and click "I'd like to make a new donation." If you do not have an account, please create an account and proceed to Step 2.
    2. Under "Gift Information" enter the amount you wish to pay. (ie: $150 for a deposit)
    5. In the drop-down box marked "Please select..." choose "other."
    6. In the "please specify" box, type "2012 National Youth Gathering Deposit"
    7. Enter credit/debit card information
    8. Click "Make Donation"