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Youth Explosion Registration Form
print and mail form and check to:
Willoughby Hills Evangelical Friends Church
2846 S.O.M. Center Road
Willoughby Hills, Ohio, U.S.A. 44094
(No one under 7th grade can attend.
If you are out of 12th grade you must attend as a counselor)
Name _________________________________________
Youth Explosion Group Leader _____________________
Address ________________________________________
City ________________________ State ____ Zip _____
Phone ( ) _____________________________________
Church attending with ______________________________ Church phone
( ) ________
STUDENTS ONLY:
M or
F Birthday (m/d/y) ___/___/___ Grade (circle one) 7 8 9 10 11
12
COUNSELORS ONLY: Track you're attending Jr High (7-8 grade) OR Sr. High (9-12
grades) M
or F
Roommate Preferance (no roommate changes once registered) ___________________________
PARENTAL RELEASE
In consideration for my teen being allowed to participate in
Youth Explosion, my
spouse and myself, hereby assume all risks in connection with
this event and I
further release Willoughby Hill Friends Church from any claims,
judgements, or
liability for any injury or damage that may occur while our teen
is attending Youth
Explosion.
Parent's or Guardian's Names (please print and sign below)
____________________ __________________________
____________________ __________________________
Date ________ My Insurance Co. _____________
Policy # __________________
Allergies _________________
FIGURING COST
Full payment required with registration. In case of cancellation,
$25 is non-refundable
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Way Early |
Early Bird |
Regular |
TOTAL COST |
| CONFERENCE |
$68 |
$78 |
$85 |
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| HOTEL FEE |
$30 |
$30 |
$30 |
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| HOST FAMILY |
$0 |
$0 |
$0 |
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Make checks payable to: Willoughby Hills
Friends Church
FOR OFFICE USE ONLY
Date received _____
Amount received ______
Date postmarked ______
PAYMENT _____
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