Youth Evangelism Conference Registration | 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

Deposit of $50 by December 15 for early bird special. 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

Do you have a 2023 Medical/Travel release on file? *

Yes, from an earlier trip this in 2023

No, I need to fill it out

Even though you have filled out a medical release from 2023, we will need a new medical release for 2024.

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. It will need to be signed by a parent or guardian at camp check in. Separate release for StudentLife Camps will also be required.

The following release will be included:
"My permission is granted for any Mount Pleasant Baptist Church staff member or sponsor in charge of the Student Life Camp 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 this form will be available for review and must be signed by a parent or guardian at camp check 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