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Registration Form 2009

This registration form is for the eMerge event being held at Luther College on November 14, 2009. It requests basic contact information for attendees, including name, gender, birthdate, address, emergency contacts, and any medical issues or hospitalization numbers. For attendees under 18, it requires a parent/guardian signature giving permission to attend and acknowledging the waiver of liability. It provides details on crash rooms being available overnight and specifies to check a box if an overnight stay is required, with pillows and breakfast provided. The form should be returned with payment by November 6th to the listed Luther College address.

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LGR
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55 views

Registration Form 2009

This registration form is for the eMerge event being held at Luther College on November 14, 2009. It requests basic contact information for attendees, including name, gender, birthdate, address, emergency contacts, and any medical issues or hospitalization numbers. For attendees under 18, it requires a parent/guardian signature giving permission to attend and acknowledging the waiver of liability. It provides details on crash rooms being available overnight and specifies to check a box if an overnight stay is required, with pillows and breakfast provided. The form should be returned with payment by November 6th to the listed Luther College address.

Uploaded by

LGR
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
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Registration form

Registration deadline is November 6th 2009

Please print legibly:

Name:______________________________________ Gender (circle): Man Woman


Birth date (M/D/Y):_________/_________/________ Grade: _________________
Street address: ______________________________ Postal code_____________
City/town: ___________________________ Province: _____________________
Telephone: ________________________ Cell phone: ______________________
Email address:______________________________________________________
In case of emergency, call:____________________________________________
Relation: _________________________ Telephone: ________________________
If you have health concerns, allergies or special dietary needs that we should be
aware of please state them here:

Hospitalization number: _________________(Please bring your hospitalization card with


you)
Family doctor:__________________________

Parent/guardian signature: (if youth attending is under 18 years of age)


I give permission for ______________________________________________ to attend the eMerge event
at Luther College on Saturday 14 November 2009 from 1:30 pm to 1:30 am (Registration
begins at 12:30 pm.) I understand that Luther College, Regina Evangelical Lutheran Youth
(RELY)and the Diocese of Qu’Appelle are not liable for any loss or damage to personal property
or injuries during the duration of this event. I understand my son’s/daughter’s name and
address will be added to the Luther College U of R mailing list.

Signature:_____________________________________________________________

Note: Crash rooms will be provided for both boys and girls. Each will have a supervisor of the
respective gender. If you wish to stay the night at Luther College please specify. There will be
no cost for staying the night. Pillows and breakfast will be provided but toiletries, sleeping
bags, air mattresses and other items will not. Pick up by 11am.

______ Please place a checkmark here if you require accommodations the evening of 14
November 2009.

How did you hear about the event?


___Poster ___Friend ___Invitation in the mail
___Church ___Website ___School
Other_______________________________________________________________
Please submit photo release form along with registration form.

Return this form to:


Luther College- Attention “eMerge”
University of Regina
3737 Wascana Parkway
Regina, Saskatchewan S4S 0A2
Cheques should be made payable to: Luther College ($30 a person,
additional siblings $15)

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