Please register each participant separately.

 

Name    Gender:  Male    Female

 

Address

 

City    State    Zip

 

Phone    Age (12-18)    T-shirt size

 

Email (required)

 

Jurisdiction    Annual Conference

 

Local Church    UM Organization

 

Pastor

 

Parent or Guardian    Phone

 

Address

 

City    State    Zip

 

Emergency Contact    Phone

 

Medical Insurance Carrier    Policy Number

 

Please indicate any medical concerns:

 

Please enter your full name in the blanks below as your electronic signature:

Parent's Signature    Youth's Signature

 

 

All forms must be signed by a parent or guardian before we can accept the registration.  Your signature gives permission for your daughter or son to receive medical attention if the need arises, while a participant in the Youth Harambee experience.