2023 REVIVE REGISTRATION PROGRAM Students must be at least 12 years of age to participate in Street Invaders Revive Street Invaders Revive runs from Friday evening Saturday evening. Friday dinner an Saturday breakfast lunch and dinner provided. Please select which you will attend. * Friday-Sunday ($70) Friday Night Only ($20) Which Revive are you registering for 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 PARENT/LEGAL GUARDIAN EMERGENCY CONTACT We require the contact information for one parent or guardian. Primary Contact Parent/Legal Guardian #1 Full Name * First Name Last Name Relationship to Student * Email * Cell Phone Number * (###) ### #### Secondary Phone Number (###) ### #### Secondary Contact Parent/Legal Guardian/Other #2 Full Name * First Name Last Name Relationship to Student * Email * Cell Phone Number * (###) ### #### Secondary Phone Number (###) ### #### MEDICAL DETAILS Health Card Number * Health Card Province * Do you have any history of the following: Seizures Fainting Spells Eating Disorders Respiratory Problems Mental Health Issues Self-Harm Allergies Other If other was chosen, please specify here (please also add any dietary restrictions) CHURCH DETAILS Please provide us with information about your church/youth group. Church Name * Youth Pastor or Youth Leader's Name * First Name Last 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 Payment options: 1. Visit the 'donate' page on our website and specify "Street Invaders - Revive" in the comment box. 2. E-transfer to finance@unitedyouthoutreach.ca and specify "Street Invaders - Revive" in the transfer. 3. Pay by card or cash upon arrival Thank you!
