Youth Leader Registration Form

Registration for Youth Leaders
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender*
Birthdate*

MonthDayYear
E-mail*
All correspondence will be sent to this address.
Home Phone Number*

Area CodePhone Number
Mobile Phone*

Area CodePhone Number
Talents
Musical/Instrumental/Artistic/Other - Let us know what you can do!
T-Shirt Size*
Home Church
Include Full Name of Church, City, and State
Pastor's Name
Medical Information
Emergency Contact*

First NameLast Name
Relation*
Relationship to Emergency Contact (i.e. friend, relative, neighbor, pastor, etc.)
Emergency Contact Phone Number*

Area CodePhone Number
Family Physician

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Physician Phone

Area CodePhone Number
Insurance Carrier
Insurance Plan #
Insurance Policy #
Last Tetanus Booster

MonthDayYear
Blood Type
Allergies?
Food, insects, drug, etc.
Any Other Medical Concerns or Notes?
Consent/Liability Release

For All Participants: Typing your name below serves as an electronic signature verifying that all the above information is correct and that you intend to follow all the established rules for the rally as outlined in the Youth Leader Christian Conduct Covenant (posted on the rally website).
Electronic Signature*
Type Full Name
Youth Leader Consent

I have read the informational materials regarding planned activities. I give WELS North Atlantic District Commission on Youth and Family Ministry and WELS Michigan District Commission on Youth and Family Ministry right to use any of my images/photos and comments for publicity purposes related directly to the mission of the NADCYFM and MDCYFM and the 2017 Regional Rally. Furthermore, I acknowledge that I remain fully responsible for all of my actions. I release from liability and forever discharge WELS, WELS CYFM, WELS North Atlantic District, WELS Michigan District, Xavier University, their agents and servants, successors and assigns, directors, trustees, officers, employees, and other representatives from any and all liability, claims, losses, damages, costs, expenses and causes of action either at law or in equity that I may have as a result of my participation in, attendance at, and travel to and from the 2017 Rally.
Electronic Signature*
Type Full Name
Date of Signature

MonthDayYear
My Products
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Payment Amount$260.00
Upon clicking "Register", you will be redirected to the payment portal of Grace Evangelical Lutheran Church. The payment will show up as "NADCYFM" on your credit card statement.
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Registration for Youth Leaders

Medical Information

Consent/Liability Release

Youth Leader Consent