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

= Required

$80.00 (USD)

NO REFUNDS WILL BE GIVEN AFTER MARCH 28TH.

GENERAL INFORMATION



Please list two names your student would like to be in a group with. (We will do our best to accommodate requests but not every request can be granted) Please list only 2 names:

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 and nurse have permission to do the following:











INSURANCE INFORMATION

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.

NO REFUNDS WILL BE GIVEN AFTER MARCH 28TH.