<- Back to DW Info Page "*" indicates required fields Student InfoStudent's Name* First Last Student's Age* Student's Grade*–9th10th11th12thStudent's Gender*–MaleFemaleStudent's School* Student's T-Shirt Size**Adult sizes only–S – SmallM – MediumL – LargeXL – Extra LargeXXL – Double Extra LargeStudent's Cell Phone*Student's Home Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is student a first time guest? Yes If student is a guest, who were they invited by?* Roommate Request*High school students will spend Friday and Saturday nights at host homes. Indicate below 2 friends that the student would like to be housed alongside. We will make every effort to put students with one of these requests. Does student have plans to attend Spain Park's Sadie Hawkins dance?(Skip if this does not apply to you) Yes Spain Park Sadie Hawkins*In order to be placed in a host home for the weekend. Students attending the SPHS Sadie Hawkins dance must return to the church by no later than 10:15pm Saturday night. I will be back by 10:15pm. I will not be back by 10:15pm and do not need to be placed in a host home. Will student be leaving at any point during the weekend?(do not check anything if staying the entire weekend) Yes When will the student be leaving?*Please note day and time. When will the student return?*Please note day and time. Does student require any special accommodations?i.e. dietary restrictions or sensory sensitivities Parent InfoParent/Guardian (Primary Contact)* First Last Other Parent/Guardian – Name First Last Parent/Guardian – Cell Phone*Other Parent/Guardian – Cell PhoneParent/Guardian Email* Media Release Attention: By submitting this form you thereby give permission for photographs/videos from this event in which your child appears to be used for publications and public relations activities by Riverchase United Methodist Church. This usage may include use in print media, electronic media, and social media. Please email the RSM Youth Staff at info@riverchasestudents.com if you DO NOT wish for photos/videos of your child to be published in church publications.PaymentPayment Options* Credit/Debit Card Payment Scholarship Payment Optional Scholarship DonationIf you would like to help provide funds for a student scholarship to Discovery Weekend, please insert the amount above. Scholarship CodeIf you would like to request a scholarship please contact Taylor Sallade at TaylorS@riverchaseumc.org Discovery Registration Fee Price: Discovery Registration Fee Price: Total To complete registration please submit payment through PayPal. Refunds are unavailable after January 16.Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.
