D-NOW 2023 Registration
Please fill out this form and click submit.
Name
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Gender
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Please select one option.
Female
Male
Student Grade
*
Please select one option.
6
7
8
9
10
11
12
Select Option
6
7
8
9
10
11
12
Food Dislikes/Allergies:
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Student t-shirt size
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Email
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This address will receive a confirmation email
Student Phone
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Address
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AE
AK
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AP
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AS
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BC
CA
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DC
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FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
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MO
MP
MS
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NB
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Parent/Guardian Name
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Parent/Guardian Phone Number
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If you do not attend Bethany (or Refuge), who invited you to D-NOW?
*
Insurance Company
*
Policy Number/Member ID
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Group Number
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Medical Info (medications, allergies, special needs; if none, mark N/A)
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Emergency Contact Person 1
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Emergency Contact Person 1 Phone
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Emergency Contact Person 2
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Emergency Contact Person 2 Phone
*
LIABILITY RELEASE: In consideration for the opportunity to participate in the described activity, the Participant (or parent/guardian if the Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The Participant (or parent/guardian) accepts personal financial responsibility for any injury sustained during the activity or during transportation to and from the activity. Further, the Participant (or parent/guardian) promises to indemnify, defend, and hold harmless the activity sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “Sponsor”) for any injury related directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the Sponsor or otherwise. If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel of the American Arbitration Association for final resolution. MEDICAL TREATMENT PERMISSION: The undersigned does authorize any adult acting as a representative of the Church, in whose care the student has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the student under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned student pursuant to this authorization. Additionally, should the need arise an adult of the Church may assist the student with basic first-aid, to include the administration of over-the-counter medication (as agreed to in writing or verbal consent), and the undersigned agrees to release, forever discharge, agree to hold harmless, assume liability for and defend the Church, its directors, employees, volunteers and agents from any and all liability, claims or demands for personal injury, sickness, emotional or mental sickness, or death, should such incidents arise out of the treatment of the student. EARLY RETURN HOME POLICY: Should it be necessary for my student to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. MEDIA RELEASE. The undersigned does hereby give permission for the staff and volunteers of Bethany Baptist Church to photograph, videotape and/or voice record my student for purposes of in-house church use and/or for public information for promotion of the church (i.e. brochures, websites, newspapers, radio, television or other promotional mediums).
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Signing below is an affirmation that I am the legal parent/guardian (the “undersigned”) of the above student, that the information provided in this form is complete and accurate and that I give permission for my student to attend and participate in this activity through Bethany Baptist Church. Furthermore, I affirm that I have read and understand in its entirety the
*
Please select all that apply.
I agree
I disagree
Student conduct. Students who attend functions provided by Bethany Baptist Church are expected to understand and adhere to all guidelines outlined in the Conduct Covenant. A copy of this document can be found online: www.WeAreBethany.com/refuge-events. Have you and your student read the guidelines outlined in the document and agree to everything contained therein?
*
Please select all that apply.
Yes
No
ELECTRONIC SIGNATURE. By selecting 'I agree' above and entering my FULL NAME in the space below I recognize that this is equivalent to my legal signature. ENTER YOUR FULL NAME in space below as your signature and affirmation.
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Payment Options
*
Please select one option.
CARD PAYMENT ($50) includes processing fee)
CASH/CHECK ($50 in-person)
Due to financial hardship, I'm in need of a full/partial scholarship
Select Option
CARD PAYMENT ($50) includes processing fee)
CASH/CHECK ($50 in-person)
Due to financial hardship, I'm in need of a full/partial scholarship
If partial/full scholarship is needed, please explain your need here. (if none, mark N/A)
*
Payment
CARD PAYMENT including processing fee (50)
CASH/CHECK PAYMENT in person (0)
FULL/PARTIAL SCHOLARSHIP (enter amount you are able to pay)
CARD PAYMENT including processing fee (50)
CASH/CHECK PAYMENT in person (0)
FULL/PARTIAL SCHOLARSHIP (enter amount you are able to pay)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
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AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
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YT
Submit
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