LEADer REVIVE REGISTRATION PROGRAM You must be 18+ years old to be a leader at Street Invaders Revive Street Invaders Revive runs from Friday evening to Saturday evening at lunch. Dinner is provided on Friday evening. Breakfast, lunch and dinner provided on Saturday. Please select which you will attend. * Friday - Sunday Friday night only Which Revive are you applying to lead at this year? * BC AB SK MB PERSONAL DETAILS Full Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone Number * (###) ### #### Email * Date of Birth * MM DD YYYY Gender * Male Female EMERGENCY CONTACT We require the contact information for one emergency contact Full Name * First Name Last Name Relationship to Leader * Cell Phone Number * (###) ### #### Secondary Phone Number (###) ### #### MEDICAL DETAILS Dietary and Health Concerns Please provide information about any dietary restrictions or health concerns we should be aware of CHURCH DETAILS Please provide us with the name of your church. Church Name * Will you be staying overnight onsite at Street Invaders Revive? * Yes No Photo Release * I give Street Invaders permission to use my photo/video/audio of my voice in current and future promotions. Yes No Thank you!
