Young People Being and Bringing Christ Wherever They Are

YOUTH FOR CHRIST NATIONAL CONFERENCE

Campaspe Downs Country Resort, 1302 Trentham Road, Kyneton, VICTORIA 6th - 8th July 2012 __________________________________________________________________________________
REGISTRATION FEE: EARLY BIRD: AUD$135 if paid before 30 April 2012 REGULAR FEE: AUD$145 if paid between 1 31 May 2012

Note: Please submit form and payments to your local YFC Couple Coordinator before 31st May 2012.

NAME DATE OF BIRTH [DD/MM/YY] CFC YFC Chapter/ Cluster Area AGE GENDER M F

MEDICARE NUMBER (For Australian residents) HOME ADDRESS (street/suburb/state/postcode/country)

PHONE NUMBER EMAIL ADDRESS FATHERS NAME

FAX NUMBER

MOTHERS NAME PAYMENT DETAILS: BANK DEPOSIT INTERNET TRANSFER CREDIT CARD DETAILS: CARDHOLDERS NAME CARD MASTERCARD VISA CARD # CARDHOLDERS SIGNATURE _____________________________________________________________________________ CREDIT CARD

PERMISSION NOTE I give permission for my son/daughter ________________________________ to attend the CFC Youth for Christ Youth Conference on 6th 8th July 2012 in Melbourne, Australia I also give permission for the YFC Coordinators to seek medical or hospital aid for my child in case of accident or emergency. In case of such emergency, please contact: 1. Name _______________________________ Phone No____________________ 2. Name _______________________________ Phone No____________________

Is your child allergic to any medicine/food? Please name the medicine/food: ___________________________________________________________________________ Is your child at present on any medication? If so, please name medication ___________________________________________________________________________ Is your child on a special diet?

All payments, flight or bus details and registration forms are to be handed to, or remitted through, the YFC Couple Coordinators in your area. Area YFC Coordinators should submit a summary report to the Melbourne Conference Committee.

Parent/Guardian Signature _______________________________________ Date __________________ RELEASE AND INDEMNITY

In consideration of Couples for Christ (CFC) and its family ministry Youth for Christ (YFC) accepting my attendance to join the YFC Youth Conference (YCON): I hereby release CFC YFC and its YFC Couple Coordinators and other representatives in Melbourne from all cost, liability, and loss or damage incurred or suffered by me directly or indirectly outside and during the course of the Conference; I waive any claims I have, or may at any time have, against CFC YFC and its representatives and I agree, by accepting the additional inherent dangers and risks not to make any claim against or seek any compensation from CFC YFC and its representatives in respect of any personal injury, illness or death suffered by myself or damage to or loss of property sustained by me as a result of my stay before, during and after the actual Conference. Print Name ________________________________________________ Signature: __________________________________________________ Office use only Received by: No.