Full Name

Grade you will be ENTERING in the Fall

9th
10th
11th
12th
Calss of 2018 Graduate
Adult

Please list your parent(s)/guardian(s) information. Include: Name(s), address, contact information (phone #, email, etc)

Please list any and all allergies, injuries, medical conditions, or special needs the student requires. These will be kept confidential and are for the sole purpose of providing the best care for the student while we are on the trip

Please list all medicines the student is currently on and instructions for administering those medicines while on the trip

Please give your top 3 choices for roommate(s). We will make every effort to room you with someone on your list as long as it is possible

Select your T-Shirt size

Youth Large
Small
Medium
Large
X-Large
XX-Large

By completing this registration form, I understand that I am signing up for a spot on NUCleus Student Ministries trip to CIY MOVE in Cleveland, Tennessee. I understand that by registering, the church will be required to pay my costs upfront, and I agree to pay these costs (as listed above) IN FULL before we leave for the trip. I understand that any other arrangements concerning payment MUST be made with and approved by Billy BEFORE registering. I also understand that by filling out this form, I am agreeing to obey the rules and instructions given to me by CIY staff, Billy, and the adults attending this trip. I also understand that in order for my registration to be complete, I must have filled out every area of this form AND brought my $50 deposit to Billy

I agree
I disagree (this nullifies registration)

In order to complete your registration, your parent/guardian MUST confirm with Billy. Please select a method below to do so:

Confirm by phone with Billy. Cell - 386-956-9724 Office - 386-734-9141
Confirm with Billy in person