Youth Seminar

PERSONAL INFORMATION

First name

Last name

Birthday

Month

Day

Year

This event is for 12 years or older.

Address

Email

Phone

Add country area code (example +1)

EMERGENCY CONTACT

Parent, guardian, etc.

Name

Phone

Add country area code (example +1)

City, State

MEDICAL HISTORY

List any medications you take

List any allergies (including food allergies)

Physical difficulties that we should be aware of

PARTICIPANT’S AGREEMENT

Please read the Conduct Guidelines before signing below.

I agree to respect those in responsibility, to do my part in fulfilling the purpose of this seminar, and to abide by the Conduct Guidelines at all times. I understand that should I fail to do so, I will be sent home at my expense and will forfeit all registration fees.

Full name

Date signed/submitted

Month

Day

Year

By checking this box you agree to electronic signature

PLEASE WRITE A SHORT DESCRIPTION OF WHY YOU WOULD LIKE TO ATTEND THIS SEMINAR.

FINANCIAL INFORMATION

Cost, including food and lodging for the seminar program, is USD $480. You may include payment in full with this form or pay remainder upon arrival at seminar. (Check the box that applies)

Pricing

Seminar $480 (lodging and all meals)

Seminar $175 (lunch only no lodging)

Seminar and Convention $830 (all meals, does not cover transportation to the convention in Georgia)

Prices for those attending with youth but not part of the seminar (parents, guardians, etc.)

Pricing

Lodging and food $450 (three meals)

Lunch only $140 (entire seminar)

Lunch only per meal $12 (advance notice required)

If making payment online please include full name along with payment. Failure to do so may result in money being lost.

Payment Options

Online Payment (PayPal: treasurer@VCsdarm.org | Zelle: treasurer@VCsdarm.org)

Pay in Person

If making payment online please include full name along with payment. Failure to do so may result in money being lost.

If I elect to make payment via an online method, I hereby agree to provide my full legal name along with the payment submission. I further acknowledge and agree that, should I fail to include my full name as required, any funds remitted may be deemed forfeited and non-recoverable.

PARENT’S AUTHORIZATION

If you are under the age of 18, a parent must sign. If 18 or older, please sign yourself.

Parent's Signature

By checking this box you agree to electronic signature

Date signed/submitted

Month

Day

Year