1. 1 Registration Form
  2. 2 Review
  3. 3 Receipt

= Required

WE WILL ACCEPT CANCELLATIONS WITH A FULL REFUND UNTIL JANUARY 10, 2018.

GENERAL INFORMATION



EMERGENCY CONTACT INFORMATION

HEALTH HISTORY
















MEDICAL WAIVER/PHYSICIAN INFORMATION

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











INSURANCE INFORMATION

MEDICATION INFORMATION

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 an adult leader at check in. The leaders will administer the medications throughout the trip.












PAYMENT OPTIONS

At this time you can pay the full amount of $1,200 for the trip, or you can make payments. However, for the first payment, you must make a minimum down payment of $400 to register for this trip. If doing a payment plan, the first $400 is due upon registration, second $400 due on January 10th, and the final payment of $400 is due on March 1.
(USD)
By electronically signing below, I affirm that I am at least 18 years old; or this form has been filled out and/or approved by a parent or legal guardian.

WE WILL ACCEPT CANCELLATIONS WITH A FULL REFUND UNTIL JANUARY 10, 2018.