Teen Vision Lock-In

Teen Name*

First Last

Address*

Street Address City ZIP / Postal Code

T-Shirt Size*

Teen Date of Birth*

Grade*

What grade are you in.

Parent/Guardian Name*

First Last

Home or Cell Phone #*

Work Phone #

E-Mail Address*

What's the best email address we should use to reach you?

Teen's Allergies/Medical Conditions

Medical Release*

I, the parent/guardian of the child listed above, give permission to the New Vision leadership to authorize or administer medical attention to my child if they deem it an emergency during Teen Lock-in. I understand every effort will be made to contact me first or as quickly as possible. To "sign" this release, please enter your First and Last name in the field here.

In the event of an emergency, please list who we should contact and their phone numbers.*

If we can't get in touch with you or your spouse, please list individuals (and their phone numbers) we should call.

After Lock- In, my child may be released to the following people:*

Please enter names below other than mother or father. Enter any special notes.

Teen Lock In Fee*

Price:

Teen Lock In fee

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