2023 Youth Senior Trip | Mount Pleasant Baptist Church

Date *

Family Information

Student's Name (First + Last) *

Student Email Address (Optional)

This will be used to send a copy of this registration form, and other important trip updates

Student Phone (Optional)

Parent Email Address *

This will be used to send a copy of this registration form, and other important trip updates

Mother's Name (First + Last) or Legal Guardian *

Mother's/Legal Guardian's Phone *

Father's Name (First + Last) *

Fathers's Phone *

Church You Most Often Attend *

MPBC

OtherOther

Trip Information

Payment

Cash/Check

App/Kiosk/Web

A $50 deposit will save your spot for the trip. Remainder of cost due before retreat.
If paying by credit card, use your MPBC App or pay on our website (this link will be in your confirmation email). Please forward the payment receipt to lyana.smith@mpbclife.com - this will help us greatly!
If paying by cash/check, put in envelope in Black Box by church office door.

Anything we should know about your child?

Emergency Contact *

Emergency Phone *

Is your child bringing a friend *

No

YesYes

Roommate Request(s)

More than one request can be added, but only the first one will be guaranteed

Has your child attended an overnight event in 2023 yet? *

Yes, so I filled out a Medical Release for 2023

No, I need to fill it out

Medical Release Information

Family Physician *

Physician Phone *

Family Insurance Co. *

Insurance ID Number *

Insurance Phone *

Allergies *

FoodFood

Penicillin or other drug (name)Penicillin or other drug (name)

Insect stings/bitesInsect stings/bites

Poison Sumac, Oak or IvyPoison Sumac, Oak or Ivy

OtherOther

**None**

If you choose one, a text box for more information will appear.

Is your child up to date on immunizations for Tetanus, Polio Booster, Measles, Mumps, and others? *

Yes

No (please note)No (please note)

Special Diet (name)

Please list all medications your child is taking:

Can we give your child any of these medications if the situation arises where they need it? *

Tylenol (Acetaminophen)

Motrin (Ibuprofen)

No

Medical & Travel Release

The paper Registration and Medical Release form will be created with the information on this digital form.

The following release will be included:
"My permission is granted for any Mount Pleasant Baptist Church staff member to obtain medical attention in case of sickness or injury for (student's name).

"I/We, the undersigned, do hereby release, remise and forever discharge all sponsors and Mount Pleasant Baptist Church, Colonial Heights, Virginia, from any and all claims, demands, actions, or cause of action, past, present, or future arising out of any damage or injury while participating in this event. I also agree to pick up my student or reimburse MPBC for the cost of sending my student home in the event that he/she commits any infraction of the rules, puts their fellow participants in danger, or exhibits a disruptive attitude."

I understand that I will have to check my child in and make sure that all of my child's forms and payments are turned in. I understand my child may not be dropped off without checking in. *

Yes, I understand and agree

No, I need to talk to Lyana or Luke to resolve something