2025 Youth Ski Trip
Student Registration

Please fill out this form and sign electronically.
Registration closes on February 19th.

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Gender

First Name

Last Name

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Relationship to Student

Consent and Certification

Any exceptions we should know about:

I agree to Consent and Certification

Yes

No

Medical Information

Family Doctor

Doctor's Phone Number

Insurance Company covering Child, Policy #

Medical Treatment Authorization

Emergency Contact #1 (other than parent)

#1 Phone Number

Emergency Contact #2 (other than parent)

#2 Phone Number

Medical Treatment Authorization Continued

I agree to medical consent

Yes

No

Signature for Consent, Certification, and Medical Treatment

Is your child presently being treated for an injury or sickness or taking any form of medication for any reason?

Does your child have any allergies? (including medications)

Does your child sleep walk or have night terrors?

Does your child require a special diet?

Anything else we should know...

After you submit your registration you will receive an e-mail invoice with your family's total balance.
This balance can be paid via check (please make checks out to Evangelical Bible Church with Ski Trip in the memo line) or cash to Pastor Derrick or drop off at the church office.
If you have any questions please e-mail Pastor Derrick at pastorderrick@dickinsonebc.com.

2025 Youth Ski TripStudent Registration

Parental Consent

Medical Information

2025 Youth Ski Trip
Student Registration