1. 1 Registration Form
  2. 2 Review
  3. 3 Payment Details
  4. 4 Receipt

= Required

$20.00 (USD)

GENERAL INFORMATION



Choose your student's incoming grade for the fall (2017/2018).

EMERGENCY/HEALTH INFORMATION



























MEDICAL WAIVER:

In the event the parent and/or emergency contact can't be reached, TWUMC Rebelbase Student Ministry Staff and nurse have permission to do the following:











INSURANCE/PHYSICIAN:

MEDICATION REQUIREMENTS:

All medications must be in orginal container labeled with student's name & enclosed in one ziplock bag w/ student's name.
The ziplock bag with medications needs to be given to the nurse at check in.


By typing my name below I am electronically signing this document affirming that I am least 18 years old; or this form has been filled out and/or approved by a parent or legal guardian.