Worshiplude 2012

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) ____________________________________	Birthdate (dd/mm/yy) __________________	Home Church (incl. city) ______________________
Address (street, city, postal code) _________________________________________________________________________________
Email address ____________________________________	Telephone # ____________________	Gender ______________________
Health Card Number ______________________________	Emergency Contact ____________________	Emergency Contact Phone # ______________________
Participant's cell phone # (if bringing to Ottawa) ____________________________________
Health concerns / dietary restrictions / allergies: _________________________________________________________________________________ _________________________________________________________________________________
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

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.