JHPeeps All-Nighter – Riverchase Student Ministries

Join us for the JHP All- Nighter, Friday November 17, from 8 PM to 8 AM!

Bring a friend!

Name of Participant*
First Last
Participant's Date of Birth*
MM slash DD slash YYYY
Participant's Address*
Street Address Address Line 2 City State ZIP Code
Participant's Gender*
Participant's Age*
Participant's Grade*
Parent/Guardian Name*
First Last
Insurance Company
Contract Number
Group Number
Physician
Physician's Phone
Emergency Contact
Emergency Contact's Phone
Parent 1 Cell
Parent 2 Cell
Acknowledgement*
- I have read and agree to the information and requirements presented above.
(Only participant needs to sign if 21 years of age or older. If under 21, both parents must sign unless parents are separated or divorced in which case custodial parent must sign.)

Please initial below where indicated.
Parent 1 (initials)
Parent 2 (initials)
Legal Guardian (initials)
Participant, if age 21 (initials)
Trip Participant Only
I have read the forgoing and understand the rules of conduct for participants and will abide by them as well as the directions of the leadership of the trip.
Participant (initials)*

JHPeeps All-Nighter
October 18th, 2017