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| Part 1: Participant Information |
| First Name | |
| Last Name | |
| Preferred Name (this name will appear on name-tag): | |
| Date of Birth | Girls who have not yet turned 17 and girls turning 12 by December 31, 2010 |
| Street Address | |
| City | |
| State | |
| Zip Code | |
| Country | |
| Cell Phone | |
| Home Phone | |
| Email Address | |
| T-Shirt Size | |
| Roomate Request |
Four Girls Per Room. Roommates must be no more than one year apart in age (unless related). Each girl must indicate her roommate request on her registration form.
Most girls will be coming without prior roommate selections. Girls will be placed with girls their own age. |
| Roomate First Name | |
| Roomate Last Name | |
| Roomate First Name | |
| Roomate Last Name | |
| Roomate First Name | |
| Roomate Last Name | |
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| Part 2: Parent/Guardian Information: |
| First Name | |
| Last Name | |
| Email Address | |
| Cell Phone | |
| Home Phone | |
| I approve of my daughter's participation in the Young Women's Conference and certify that she is in good health and able to participate in the conference's activities. I give consent for my daughter to receive medical attention, if required, in the event of illness or accident. I agree to be responsible for any expenses such treatments require. |
| Please describe any special physical, emotional, or medical concerns or limitations that may affect your daughter: | |
| Please list any required medication: | |
| Please list any known food, drug, or other allergies: | |
| Medical Release: This release authorizes the emergency treatment for your daughter if she becomes ill or injured while attending Young Women's Conference and parents/ guardians cannot be reached. |
| Emergency Contact Name | |
| Emergency Contact Phone Number | |
| Health/Medical Insurance Company | |
| Policy Number | |
| Medical Treatment Consent: |
I, , parent and or/legal guardian of approve of my daughter's attendance at the Young Women's Conference (YWC) and give my permission for any/all emergency treatment deemed necessary by a licensed practitioner for my child if I am unavailable. I understand this authorization does not cover major surgery unless the medical opinions of one other physician or dentist, concurring in the necessity for such surgery, are obtained prior to the performance of surgery. I agree to be responsible for any expenses incurred for such treatment. YWC insurance does not cover illness (such as cold symptoms, stomach aches, etc.) or pre-existing conditions. Participants and their parents will be responsible for any costs associated with treatment in event of an emergency. This consent is valid from June 14, 2010 to June 18, 2010
Each participant is included in a YWC limited coverage ($100,000 maximum benefit) accident insurance policy while they are under the immediate approved direction and supervision of YWC. I understand that if my daughter leaves the required supervision of her counselor and/or staff without permission or leaves campus after hours or without permission, she will not be covered by the YWC insurance.
I understand that participants will be sent home if any drugs, alcohol, or cigarettes are found in their possession or use during the week. Young Women's Conference reserves the right to ensure the safety and well being of all participants and will dismiss a participant for misconduct or unsociable behavior as determined by the Directors. Fighting, stealing, shoplifting, possessing any harmful weapons, leaving campus unsupervised, leaving the dorms after curfew, and deliberately damaging hotel or program property are grounds for being sent home early. Anyone being sent home will be responsible for all transportation costs and registration fees will not be refunded. |
| CANCELLATION POLICY: Notice of cancellation must be received in writing. A $100 cancellation fee will be applied to all cancellations submitted prior to 1 April 2010. |
| I have read and agree to the cancellation policy |
| Our closing event will be Friday from 11:00 to 11:45 AM to share our week long experiences. Please indicate the number of guests (0-4) who will be attending this closing event: | |
| Please tell us how you heard about Young Women's Conference? (Please be specific) | |
