Youth Name

Date of Birth (YY-MM-DD) Select The year first

- Grade - Fall Rally is only for those in grades 7-12 - Grade - *789101112

Home Address

Mailing Address (if different)

Youth Telephone Number (if applicable)

Name of Parent/Guardian

Parent/Guardian Telephone Number

Parent/Guardian E-Mail Address

Does this youth have any allergies or medical conditions? If so, please explain

Are medications being sent? If so, please list medication, dosage, and frequency.

Does the youth have any mental health diagnoses we should be aware of?

- Which local youth group will you be attending with? - Local youth leaders are responsible for organizing chaperons to Fall Rally. By answering this question, you also agree to make your local youth leader aware of your youths attendance. - Which local youth group will you be attending with? - *Elmsdale Church of the NazareneSummerside Church of the NazareneFreetown Church of the NazareneSherwood Church of the NazareneMoncton First Church of the NazareneLutes Mountain Church of the NazareneOxford Church of the NazareneTrenton Church of the NazareneWindsor Church of the NazareneAnnapolis Valley Church of the NazareneOther

Video/Photo Release Video/Photo Release No, I do not agree with the release of my child's photo or video involvement. Yes, I am the parent/guardian of the above named minor child, and hereby consent to the authorized use of reproduction by you and anyone authorized by you, of any and all photography and other types of images, voice recordings and/or video that you have taken of my child, with our without my name, for any purpose whatsoever, including without limiting the promotion of activities of the Church of the Nazarene and its affiliated ministries.

If youth are found, or suspected to have, drugs, alcohol, vapes or other items that are illegal we reserve the right to a baggage search and confiscation of the items. If these items are found, they will not be returned. If youth are found, or suspected to have, drugs, alcohol, vapes or other items that are illegal we reserve the right to a baggage search and confiscation of the items. If these items are found, they will not be returned. I acknowledge the above statement and agree to possible search of belongings and/or removal of prohibited items.

Form Completed By