Lock-in Registration

Participant Information

First and Last Name

Date of Birth

Address

Phone

This address will receive a confirmation email

Payment $20

Parent/Guardian Information

First and Last Name

Phone (Primary)

Phone (Secondary)

This address will receive a confirmation email

Emergency Contact Name (if different)

Emergency Contact Phone (if different)

Medical & Safety

Allergies (if none, write "None")

Medical Conditions

Medications to be taken during the event

Physician's Name & Phone

Insurance Provider & Policy Number

Permissions

During the event, we may take video and/or photos of the event including games and discussion. Let us know if you're ok with this.

Photo/Video Release

Yes, I give permission No, I do not give permission

Medical Treatment Authorization

Yes, I consent to medical treatment if needed No, I do not consent to any medical treatment

Participation Waiver

I understand and accept that participation involves risk, and I release Starting Point Church from liability.

Event Logistics

List any dietary restrictions we should be aware of.

List any special needs or accommodations requested.

Church and Friendship Info

From another church? Which one?

Who invited you to this event?

Signatures

Parent/Guardian Digital Signature (Type your full name)

Date

Student Agreement

I agree to follow the lock-in rules and respect leaders and participants.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Oct 10-11, 6 PM - 10 AM

Please fill out this form and click submit.