Friday, June 23 Monday, June 26

Early Bird and Mission trip registration is Oct. 2nd

Time to register for the 2017 Youth Rally and Mission Trip! We know that God has some great
things planned for Aftershock this year. The costs are going up but we have worked out a great
deal to try and help our families this year along with lots of fundraising opportunities.
We are back with Group Mission Trips Weekend Workcamp for our trip. We will be heading
to Scranton, PA from 6/23-6/26. The remaining balance after deposit will only be $249 with no
payment until March for plenty of time to sell 10 stocks to cover the remaining payment.

Event
Youth Rally

INDIVIDUAL REGISTRATION
Cost
# of Youth/Adult
$120 (Early Bird)
x ______
$130 (Non-Early Bird)

Total
= ______

Mission Trip

$60 deposit

x ______

= ______

Both (YR+MT)

$170 (savings of up to $20)

x ______

= ______

TOTAL:
Event
Youth Rally

MULTIPLE REGISTRATIONS (same household)

Cost
# of Youth/Adult
$110 (Early Bird)
x ______
$120 (Non-Early Bird)

______
Total
= ______

Mission Trip

$50 deposit

x ______

= ______

Both (YR+MT)

$150 (savings of up to $20)

x ______

= ______

TOTAL:

______

Youth Name:
Medical Form: Youth Group
Grade:

Youth Rally

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender:

male

female

Attended in past:

Youth Rally

Mission Trip

Parent Email:
Payment:

check (#

) cash

Amount:

Checks Made payable to: Gethsemane UMC

Return forms and $ to Jordan 302-448-5328 or forstonj@verizon.net

Additional registrations:

Youth Name:
Medical Form: Youth Group
Grade:

Youth Rally

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender:

male

female

Attended in past:

Youth Rally

Mission Trip

Medical Form: Youth Group

Youth Rally

Youth Name:

Grade:

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender:

male

female

Attended in past:

Youth Rally

Mission Trip

Medical Form: Youth Group

Youth Rally

Youth Name:

Grade:

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender:

male

female

Attended in past:

Youth Rally

Mission Trip

GETHSEMANE UNITED METHODIST CHURCH

YOUTH MINISTRY
2016-2017 Emergency Medical Information
Personal Information
Participant's Name: _____________________________________ Date Of Birth M/D/Y ____/_____/____
Home Address: _________________________________________ Home Phone: (_____) ______________
City/State/ Zip: _________________________________________
Parent/Guardian Name(s): _______________________________________________
Mom's Cell Phone #: ________________________________

Mom's Work #: (____) _________________

Dad's Cell Phone #: __________________________________

Dad's Work #: (____) __________________

Medical Information
Any current medical conditions or problems?

If so, describe:_______________________________________

_________________________________________________________________________________________
Any allergies?_____________________________________________________________________________
Taking any prescribed medication? ____________________________________________________________
Past medical history/injuries we should be aware of: ______________________________________________
Date of last Tetanus shot:____________________________________________________________________
Name of physician: _____________________________ Phone #: ___________________________________

Insurance Information
Group Or Family Hospitalization Insurance Company: _________________________________________________
Insurance Company's Address: ____________________________________________________________________
Agent's Name: ___________________________________________ Phone #: ______________________________
Group#: ________________________________________________ Policy #: ______________________________
In Case Of EMERGENCY (If Parent Can't Be Reached) Call: ___________________________________________
Day Phone Number: _____________________________________ Night Phone #: __________________________

Waiver of Responsibility
I,
, legal parent or guardian of __________________ give
my permission to him/her to go on all camps, trips, & retreats, and to participate in all activities
for the 2016-2017 school and summer. I hereby release the church, its staff, and volunteer
counselors of any liability in the event of accident or injury.
Signed: ________________________________________

Date: ______________

Gethsemane United Methodist Church Youth Group

PHOTO/VIDEO RELEASE FORM (UNDER 18 FORM)
I, _________________________________________________, GRANT/DO NOT GRANT (please circle)
permission to the Gethsemane United Methodist Church Youth Group to use, reproduce and communicate the
photographs and videos taken of my child _______________________________(name) at all GUMC Youth
Group gatherings, social and spiritual activities and camps for the purposes of GUMC Youth Group
publications (e.g. Promotional Youth Group Videos, Newsletters, GUMC Youth Group social media group
pages, etc.).
I also, GRANT/DO NOT GRANT (please circle) permission to the Gethsemane United Methodist Church
Youth Group for my childs name to be published alongside any photographs that are released.
I understand that I am entitled to request the withdrawal of any photographs that I do not want to be published
of my child, and sign a new form if I change my mind about general permission for publication of photographs
of my child. Thank you for your assistance.
Signed: ........................................................................... Date: ........................................
I would not like my childs photographs/videos to be published in the following (please circle):
GUMC Aftershock promotional videos
GUMC Aftershock Facebook/Twitter/Instagram group page
(If you choose to not grant permission, please have a conversation with your child(ren) about why you have
made that decision. This way they can be aware enough to step out of group photos without drawing attention
to themselves because someone has to ask them to step out of the photo. Thank You.)