THE EVENT: DIVIDED X UNITED

Name

Grade (Fall of '26)

Home Church

Parent Email

This address will receive a confirmation email

SAFETY FORM

Every registered student must have a completed safety form to attend THE EVENT

Date of Birth

Address

Mother's Name / Phone Number

Father's Name / Phone Number

In Case of Emergency, call:

Emergency Contact #2 (Name and Phone Number)

FOOD ALLERGIES

Food Allergies:

MEDICAL HISTORY / MEDICATIONS

Any Known Medical Conditions:

Any Behavioral Issues to be Aware of?

Medications / EpiPens:

SHIRT SIZE

Select Size

Small Medium Large X-Large 2X-Large

PAYMENT

Cost: $50.00 Per Person
Cost includes students entry fee, 11 meals, wristbands, small group material and themed shirt.

PAYMENTS CAN BE MADE ONLINE -OR- IN PERSON

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Please fill out this form and click submit.

THE EVENT: DIVIDED X UNITED

Description

Please Fix the Following