Greater St. Louis Area FCA - HLCRegistration

Greater St. Louis Area FCA

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Huddle Leadership Conference Registration

Please completely fill out all listed fields before submitting. If you would like for us to contact you so you may pay by a credit card, simply check the box at the end of the form.

Student name

Please select gender

School

I am registering for	HLC #1 HLC #1 (alternate) HLC #2 HLC #2 (alternate)

Mailing Address
City, State & Zip
Home Phone
Student cell phone
Birthdate
Grade
T-shirt Size

Emergency Contact Information
Emergency Contact Name
Best Daytime Phone

Family Medical Information
Company Name
Policy Number
List any known allergies or medical conditions

I authorize the administration of emergency medical treatment to the subject of this form. I understand that all reasonable safety precautions will be take at all times by the Greater St. Louis Area Fellowship of Christian Athletes (FCA) and the FCA will not be held liable for any accident, injury or disease incurred by the subject of this form. I understand that in the event medical intervention is needed, every attempt will be made to contact the person(s) on this form immediately.
Authorization for treatment*	I am the legal parent or guardian of the student listed on this form and I DO agree to the terms and conditions listed above. I am the legal parent or guardian of the student listed on this form and I DO NOT agree to the terms and conditions listed above. I am NOT the legal parent or guardian of the student listed on this form and a insurance waiver NEEDS TO BE MAILED.

	Please contact me by phone so I may pay by credit card

* indicates a required field

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