Registration Form

Registration

July 9th, 2022

6th - 12th Grade Only

Please have your parent/guardian complete the form below to register for the Conference.

Full Name
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Parent/Guardian Name
*
Parent/Guardian Phone Number
*
Age
*
School Grade
*
Email Address
*
Address (include PO Box)
*
City/Zip Code
*
Any medical concerns that we should be aware of? If so, please list them below:
Family Doctor & Hospital Preference (in case of an emergency):
*
Emergency Contact Information in case you can not be reached (please include names and phone numbers)
*
Photo Release - I hereby grant permission for Utica Youth Conference to record pictures or videos of my teen while attending the UYC event. I also give permission to Utica Youth Conference to use these images or videos in print and online publications including websites and social networks knowing that their identity is kept anonymous. (Please select an option below)
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By initialing below, you release Utica Youth Conference and its authorized representatives and staff from liability of any kind and character upon any claim, demand, or cause of action which might be asserted in behalf of said minor against said church, representatives, or staff. Furthermore, in the event of an accident or injury, if the event leader's responsible for my teen or their representatives are unable to contact the parent(s) or guardian(s), we hereby grant permission to the event leader's responsible for my teen or their representatives to administer necessary first aid, and/or to take my teen to the nearest medical facility for additional treatment by a physician/medical specialist. In addition, I will notify Utica Youth Conference in writing of any changes in medications, allergies or medical conditions that occur for my teen while my teen participates in the events of Utica Youth Conference, Utica Ohio.
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Please click on the checkbox to continue
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You will be redirected to the main page once you click submit.

Registration

July 9th, 2022

6th - 12th Grade Only

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