Time to register for the 2017 Youth Rally and Mission Trip! We know that God has some great things planned for Aftershock this year. The costs are going up but we have worked out a great

deal to try and help our families this year along with lots of fundraising opportunities.

We are back with Group Mission Trips Weekend Workcamp for our trip. We will be heading to Scranton, PA from 6/23-6/26. The remaining balance after deposit will only be $249 with no

payment until March for plenty of time to sell 10 stocks to cover the remaining payment.

INDIVIDUAL REGISTRATION Event Cost # of Youth/Adult Total

Youth Rally $120 (Early Bird) $130 (Non-Early Bird) x ______ = ______

Mission Trip $60 deposit x ______ = ______

Both (YR+MT) $170 (savings of up to $20) x ______ = ______

TOTAL: ______ MULTIPLE REGISTRATIONS (same household)

Event Cost # of Youth/Adult Total

Youth Rally $110 (Early Bird) $120 (Non-Early Bird) x ______ = ______

Mission Trip $50 deposit x ______ = ______

Both (YR+MT) $150 (savings of up to $20) x ______ = ______

TOTAL: ______

Friday, June 23 – Monday, June 26

Early Bird and Mission trip registration is Oct. 2nd

Additional registrations:

Youth Name:

Medical Form: □ Youth Group □ Youth Rally

Grade:

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender: □ male □ female

Attended in past: □ Youth Rally □ Mission Trip

Parent Email:

Payment: □ check (# ) □ cash Amount:

Checks Made payable to: Gethsemane UMC

Return forms and $ to Jordan 302-448-5328 or forstonj@verizon.net

Youth Name:

Medical Form: □ Youth Group □ Youth Rally

Grade:

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender: □ male □ female

Attended in past: □ Youth Rally □ Mission Trip

Youth Name:

Medical Form: □ Youth Group □ Youth Rally

Grade:

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender: □ male □ female

Attended in past: □ Youth Rally □ Mission Trip

Youth Name:

Medical Form: □ Youth Group □ Youth Rally

Grade:

6th / 7th / 8th / Freshman / sophomore / junior / senior

Gender: □ male □ female

Attended in past: □ Youth Rally □ Mission Trip

GETHSEMANE UNITED METHODIST CHURCH YOUTH MINISTRY

2016-2017 Emergency Medical Information

Personal Information Participant's Name: _____________________________________ Date Of Birth M/D/Y ____/_____/____

Home Address: _________________________________________ Home Phone: (_____) ______________

City/State/ Zip: _________________________________________

Parent/Guardian Name(s): _______________________________________________

Mom's Cell Phone #: ________________________________ Mom's Work #: (____) _________________

Dad's Cell Phone #: __________________________________ Dad's Work #: (____) __________________

Medical Information

Any current medical conditions or problems? If so, describe:_______________________________________ _________________________________________________________________________________________ Any allergies?_____________________________________________________________________________ Taking any prescribed medication? ____________________________________________________________ Past medical history/injuries we should be aware of: ______________________________________________ Date of last Tetanus shot:____________________________________________________________________ Name of physician: _____________________________ Phone #: ___________________________________

Insurance Information Group Or Family Hospitalization Insurance Company: _________________________________________________ Insurance Company's Address: ____________________________________________________________________ Agent's Name: ___________________________________________ Phone #: ______________________________ Group#: ________________________________________________ Policy #: ______________________________ In Case Of EMERGENCY (If Parent Can't Be Reached) Call: ___________________________________________ Day Phone Number: _____________________________________ Night Phone #: __________________________

Waiver of Responsibility

I, , legal parent or guardian of __________________ give my permission to him/her to go on all camps, trips, & retreats, and to participate in all activities for the 2016-2017 school and summer. I hereby release the church, its staff, and volunteer counselors of any liability in the event of accident or injury. Signed: ________________________________________ Date: ______________

Gethsemane United Methodist Church Youth Group

PHOTO/VIDEO RELEASE FORM (UNDER 18 FORM)

I, _________________________________________________, GRANT/DO NOT GRANT (please circle)

permission to the Gethsemane United Methodist Church Youth Group to use, reproduce and communicate the

photographs and videos taken of my child _______________________________(name) at all GUMC Youth

Group gatherings, social and spiritual activities and camps for the purposes of GUMC Youth Group

publications (e.g. Promotional Youth Group Videos, Newsletters, GUMC Youth Group social media group

pages, etc.).

I also, GRANT/DO NOT GRANT (please circle) permission to the Gethsemane United Methodist Church

Youth Group for my child’s name to be published alongside any photographs that are released.

I understand that I am entitled to request the withdrawal of any photographs that I do not want to be published

of my child, and sign a new form if I change my mind about general permission for publication of photographs

of my child. Thank you for your assistance.

Signed: ........................................................................... Date: ........................................

I would not like my child’s photographs/videos to be published in the following (please circle):

GUMC Aftershock promotional videos

GUMC Aftershock Facebook/Twitter/Instagram group page

(If you choose to not grant permission, please have a conversation with your child(ren) about why you have

made that decision. This way they can be aware enough to step out of group photos without drawing attention

to themselves because someone has to ask them to step out of the photo. Thank You.)