Worshiplude 2012
Registration Form
Must be submitted to Brian MacKinnon by January 5, 2012 with
$30 deposit. Remaining $50 will be due on January 28, 2012. Questions can be
sent to Brian at
brianmackinnon@rogers.com
or by calling 519-643-0129.
Registration and
cheques can be sent to the following address:
Worshiplude c/o
Brian MacKinnon
72 Grenfell Cres.,
London, ON, N5X 2M7
NOTE:
NO REFUNDS WILL BE GIVEN UNLESS YOU FIND SOMEONE TO TAKE YOUR PLACE!
Name (Last, First)
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Birthdate (dd/mm/yy)
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Home Church (incl. city)
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Address (street, city, postal code)
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Email address
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Telephone #
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Gender
______________________
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Health Card Number
______________________________
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Emergency Contact
____________________
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Emergency Contact Phone #
______________________
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Participant's cell phone # (if bringing to Ottawa)
____________________________________
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Health concerns / dietary restrictions / allergies:
_________________________________________________________________________________
_________________________________________________________________________________
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Would you like to go to the IMAX film at the Museum of
Civilization? ($5 Student / $6 Adult with group rate) (Circle one)
Yes No
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Parent/Guardian Consent:
I, ______________________, hereby give consent for the above
participant to participate in Worshiplude from February 10-12, 2012. I confirm
that his/her health is suitable for outdoor activities. In case of emergency, I
authorize leadership for this event to refer the above to medical authorities
on my behalf.
Participant Statement:
I, _____________________________, acknowledge that
Worshiplude is a drug and alcohol free weekend. I will not bring any illegal
drugs or any alcohol with me. I agree to turn over any medication that I bring
to the designated adult. I understand that I will be expected to abide by all
rules and guidelines for the weekend as explained at the start of the event.