Junior High Registration Form

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=200 BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Wisconsin Congregational Association</B></FONT>    |     <A HREF="index.htm" TARGET="_top" TITLE="Wisconsin Congregational Association"><U>home</U></A>   <A HREF="id22.htm" TARGET="_top" TITLE="Youth and Camp"><U>Back to Youth and Camp</U></A></div> <bR> <div> Junior High Registration Form</div> <div> Rally Registration & Consent Form</div> <bR> <DIV ALIGN="LEFT"></DIV> <div> <I>Wisconsin Congregational Association</I></div> <bR> <div> <B>Participant's (youth's) name: </B><B><U>                              </U></B><B>  Grade: </B><B><U>          </U></B></div> <div> <B>Address: </B><B><U>                                                       </U></B></div> <div> <B>Phone number: </B><B><U>                                                  </U></B></div> <div> <B>Email address: </B><B><U>                                                  </U></B></div> <div> <B>Name(s) of parent(s) or legal guardian(s): </B><B><U>                                   </U></B></div> <div> <B>Name and city of Participant's Church: </B><B><U>                                   </U></B></div> <bR> <div> I hereby certify that I am aware of, approve of, and take full responsibility for the participation of the above named Participant in the Wisconsin Congregational Association Junior High Rally.  Furthermore, I assume all risk of and financial responsibility for any loss or injury to the Participant or others that may occur as a result of negligence or misconduct by the Participant, and I release the Wisconsin Congregational Association, and its employees, volunteers, and other agents, from any and all responsibility and legal liability for loss, damage, or injury to the person or property of the Participant which may be sustained during or as a result of participation in the Rally.  </div> <bR> <div> In the event of an emergency, including illness, injury, or incapacity suffered by the Participant during the course of the Rally, I hereby authorize a Wisconsin Congregational Association Co-Advisor, a counselor, or any other adult leader to act as agent for me in consenting to any reasonably necessary X-ray examination, medical, dental, surgical, or psychological diagnosis, treatment, and/or care, advised and supervised by a physician, dentist, surgeon, psychologist, or social worker licensed to practice under the laws of the state in which the services are rendered.  I understand that I, or the applicable insurance carrier(s), will be financially responsible for any such emergency services.  I expect that attempts will be made to contact me in the event of any such emergency. </div> <bR> <div> <B>Signature of parent or legal guardian:</B><B><U>                                        </U></B></div> <bR> <div> <B>Date: </B><B><U>               </U></B><B>    Emergency phone number(s): </B><B><U>                              </U></B></div> <bR> <bR> <div> I'm coming to this Rally to make friends and to be a friend, to learn a little more about God, and to have fun!  I understand that if I fail to follow the rules and directions given by the leaders, I may be sent home at my parent(s)' expense.  I also realize that my attitude will largely determine the kind of experience that I have at the Rally, and therefore I will do all that I can to make the weekend a safe, fun, and meaningful time for myself and for my fellow “Ralliers.”</div> <bR> <div> <B>Participant's signature:                                        Date:</B></div> <bR> <DIV ALIGN="LEFT"></DIV> <div> Medical Information Pertaining to the Participant:</div> <bR> <div> <B>Allergies: </B><B><U>                                                       </U></B></div> <bR> <div> <B>Medication(s) being taken: </B><B><U>                                                  </U></B></div> <bR> <div> <B>Physical handicap(s) or limitation(s): </B><B><U>                                        </U></B></div> <bR> <div> <B>Medical insurance company: </B><B><U>                                             </U></B></div> <bR> <div> <B>Group or policy number: </B><B><U>                                                  </U></B></div> <bR> <div> <B>Any other information that you deem important for the activity leaders to know (use reverse side if needed):</B> </div> <bR> </td> </tr></table></body>