Rally 2019 Youth Registration Form

Registration for Youth Participants
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Gender*
Birthdate*

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

Area CodePhone Number
Talents
Musical/Instrumental/Artistic/Other - Let us know what you can do!
T-Shirt Size*
Home Church
Pastor's Name
Piggy backing?
Please list the sponsoring congregation and youth leader name
Medical Information
Emergency Contact*

First NameLast Name
Relationship to Participant*
(Enter Emergency Contact Relationship - i.e. aunt, uncle, friend, neighbor, grandparent,etc.)
Emergency Contact Phone Number*

Area CodePhone Number
Parent Home Phone

Area CodePhone Number
Parent Work Phone

Area CodePhone Number
Parent Mobile Phone

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 Christian Conduct Covenant (posted on the rally website).
Electronic Signature*
Type Full Name
For Parent/Guardian Consent for Youth Participants

I hereby consent to the participation of my child/ward in the 2019 WELS North Atlantic-Michigan Regional Youth Rally. I have read the informational materials regarding planned activities. My child/ward has permission to engage in all of them. I give WELS North Atlantic District Discipleship and WELS Michigan District Discipleship right to use the images and comments of my child/ward for publicity purposes related directly to the mission of the NADD and MDD and the 2019 Regional Rally. Furthermore, as parent/legal guardian of my child/ward, I acknowledge that I remain fully responsible for any actions taken by my child/ward. I release from liability and forever discharge WELS, WELS Discipleship, The North Atlantic and Michigan District's of WELS, Shepherd 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 child’s/ward’s participation in, attendance at, and travel to and from the 2019 Rally.
Electronic Signature*
Full Name of Parent/Guardian
Date of Signature

MonthDayYear
Registration Payment*
prevnext( X )
Payment Amount$295.00
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.

Upon completion of your registration you will receive an auto-respond email. In the email you will find a link to make changes to your registration prior to May 15. Any changes after May 15 should be requested by contacting rally staff directly.
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Registration for Youth Participants

Medical Information

Consent/Liability Release

For Parent/Guardian Consent for Youth Participants