Event Application

Event:	Date:
Event Details:
Cost:	Application Due Date:
Please make Checks payable to: Epworth UMC	(Please submit form & registration money to: Mark Waldrop

Student Information
Last Name:	First Name:
Grade:	Age	Gender: M | F
Phone:	Email:
Address:	City
Postal Code:

Parent / Guardian Information
Name(s):	Email:
Home Phone:	Other Phone:

Medical Information
Health Card #:	Health Card Expiry Date:
Medical Conditions or Allergies: (Please make special note of food allergies)	Medication(s) Currently Being Taken: (Please note medication names and times taken)

Permission Form

Student
I promise to abide by all rules and plans set forth by the leaders of FUEL Student Ministries / Epworth UMC, Phenix City, AL during the course of this event.
Signature:	Date:

Parent
I / we are the legal guardians of the student named above and hereby give my / our permission for the named student to participate in the above named event with the leaders of FUEL Student Ministries / Epworth UMC, Phenix City, AL. I understand that in the event of an emergency that the leaders of FUEL Student Ministries / Epworth UMC, Phenix City, AL do everything in their power to contact me personally, but that in the event that they are unable to do so, I / we give my / our permission for the leaders to seek necessary medical attention for the student named above.
Signature:	Date:

Office Use Only
Approved (Circle One): Yes / No	Paid:	Owed: