UNITE Weekend Registration

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Student Name *
Student Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
* By electronically signing below, I give my child permission to attend UNITE Weekend at First Baptist Church Pittsburg, TX on January 26-28, 2018. I have read and agree to all of the information on the brochure. My student also has permission to participate in any recreation at his/her own discretion. I realize that there is risk associated with any activity and I assume full responsibility for the welfare of my child. I will not hold First Baptist Church, nor any of its sponsors, leaders, staff, agents, or representatives responsible in case of injury or illness during or resulting from activity. This statement authorizes the church sponsors to seek medical and/or surgical treatment in the event of an emergency. *
Emergency Contact Information *
Emergency Contact Information
Phone *
Phone
Physician Phone
Physician Phone

**Please bring $30 registration fee to Kassidy Harris at First Baptist Church prior to the event.  The student will not be fully registered until payment has been accepted.