MBU Harvest Rally Registration

Attendee Information

Attendee First Name

Attendee Last Name

Attendee Email Address

Attendee Phone Number

Parent First Name

Parent Last Name

Parent Email Address

Parent Phone Number

Parent Mailing Address

Street

City

State

Zip

Country

Attendee Gender

What is the attendee's age during the MBU Harvest Rally?

What grade will attendee be in this coming fall?

Year of expected high school graduation

Name of Home Church (no abbreviations)

Youth Pastor's Name

T-Shirt Size

Adult sizes only

Medical Information

All attendees must have insurance documentation and tetanus vaccination records to participate in the MBU Harvest Rally. All prescription medications must be given to the MBU Harvest Rally Health Supervisor in their original containers with instructions for dosage and times for administration upon check-in. We recommend that your child have a physical sometime within 12 months before attending the MBU Harvest Rally.

Medical Release

You must complete a medical release to be registered for the MBU Harvest Rally.

"I, (type parent's name)..."

"...declare that I am the..."

"...of (attendee's name)..."

I hereby authorize the MBU Harvest Rally Health Supervisor to dispense over-the-counter medications as per standard medical practice. In case of medical emergency when I cannot be reached by telephone, I hereby authorize the staff of the MBU Harvest Rally to secure appropriate medical treatment such as X-ray examination, anesthetic, injection, medical or surgical diagnosis or treatment, and hospital care necessitated by injury or illness, while the above-named child is attending the MBU Harvest Rally. I agree to the release of any records necessary for referral, treatment, billing, or insurance. Services are to be rendered to the attendee by legally qualified personnel. I hereby affirm that my child has no physical conditions that will limit participation in the full range of activities being planned, except as listed below. I hereby waive and release Maranatha from any and all liability.

Parent/Guardian indicates agreement with above statement electronically by typing their full name here

Medical History

Allergies (list all)

Current Medications (list all)

Pre-Existing Injuries

Please briefly describe pre-existing injuries or other special medical conditions, or activities to be restricted. (Type N/A if not applicable)

Insurance Information

Attendee Has Insurance

Insured's Name

Insurance Company

Policy Number

Insurance Phone Number

This section is a statement from parents indicating they do not have insurance coverage for their child.

(attendee's name)

IS NOT COVERED BY INSURANCE.

IT IS OUR UNDERSTANDING THAT MBU HARVEST RALLY WILL NOT ASSUME THE RESPONSIBILITY OR OBLIGATION FOR ANY MEDICAL BILLS OR DEBTS RESULTING FROM ANY INJURY TO THE ABOVE NAMED CAMPER WHILE PARTICIPATING IN ANY MBU HARVEST RALLY ACTIVITIES.

I hereby authorize the staff of the MBU Harvest Rally located in Watertown, Wisconsin, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care necessitated by injury or illness, while the above-named child is attending the MBU Harvest Rally. Such treatment is to be rendered to the attendee under the general or special supervision or the advice of a physician or surgeon licensed to practice in the State of Wisconsin.

I hereby waive and release the MBU Harvest Rally from any and all liability.

I hereby affirm that my child has no physical conditions, which will limit participation in the full range of activities being planned.

Parent/Guardian indicates agreement with above statement electronically by typing their full name here

Immunization Information

Attendee Has Been Immunized

Date of Last Tetanus Shot

This section is a request to exercise my right to waive immunization requirements for my son/daughter,

(son/daughter's name)

This request is made based on my personal and philosophical beliefs.

I agree to hold harmless Maranatha Baptist University and the MBU Harvest Rally in the event of any possible illness or injury resulting from waiving my immunization requirement. I also understand that in the event of a suspected case of measles, it would be necessary for my child to leave the MBU Harvest Rally at that time.

Parent/Guardian indicates agreement with above statement electronically by typing their full name here

Payment Information

Payment Amount

Customer Details

First Name

Last Name

Organization Name

Email Address

Phone Number

Billing Address

Street

City

State

Zip

Country

NOTE: There are no transaction/convenience fees for credit card payments.

Payment Method

Credit CardeCheck (USA Only)

Credit Card Details

Name on Card

Card Number

CVV

Expiration Month

Expiration Year

NOTE: You have chosen a non-USA billing address and the eCheck payment method. Your eCheck payment will not be able to be processed from a non-USA bank account.

Bank Account Details

Account Holder Name

Bank Name

Account Type

Account Number

Routing Number

Confirm Account Number

Confirm Routing Number

Account Numbers Match?

Routing Numbers Match?

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Verification

By submitting this registration form I agree to allow Maranatha the right to freely use, publish, and reproduce, for all purposed, all captured audio, video, and images of the camper. (Type name below)

First Name

Last Name

Please click the button below to complete your registration. DO NOT navigate back, refresh, or close this window until you have been redirected to the confirmation page. Please do not click the submit button multiple times. The form will take a moment before information is sent to the servers.

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