Teens for Christ Summer Lock-In Registration – Lexington United Methodist Church

Participant Information
Child's Name*
Child's Home Address*
Street Address City State ZIP Code
Child's Cell Phone*
Child's Age*
Child's Date of Birth*
Grade for 2017-18 School Year*
Child's Gender*
Known Allergies?*
If yes, please list:
T-Shirt Size*
Parent/Guardian Information
Parent/Guardian Name(s)*
Parent/Guardian Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone (Mom)
Cell Phone (Dad)
Parent/Guardian Email*
Please list additional persons authorized to pick your child up:*
Emergency Contact Information
Emergency Contact Name*
Emergency Contact Phone*
Relationship to Child*
Physician Name*
Physician Phone*
Photography Information: This is to inform parents/guardians that during the lock-in, we will have staff and volunteers taking photographs of all of our activities. By registering your child you are indicating that you understand that your child’s photo may be used for our in-house promotional material as well as posted on social media sites and that you are accepting this condition.
I have read the rules and agree to abide by them.
Parent's/Guardian's Initials*