Registering As...*RetreaterYouth Sponsor/LeaderName* First Last Age*131415161718+Grade*Grade 7Grade 8Grade 9Gender*MaleFemaleAddress* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneEmail Emergency Contact Name First Last Emergency Contact PhoneGroup you're coming withT-shirt SizeSmallMediumLargeXLargeXXLargeRoommate Preference(1 only, no guarantee)List Medical ConcernsHealth Card #List AllergiesPayment Amount*$94.50 before September 11th$115.50 Sept. 11th to Sept. 21nd$125 for Walk-Ons (Sept. 22)$63 for Youth Sponsors/Leaders(Price includes GST)Payment Type*PayPal On-lineCredit Card (through NBC's Bookstore)Mail a chequePay with PayPal online, Credit Card by calling the College office @ 306.862.5095 or make Cheque out to Nipawin Bible College, (under memo: three60fiveJR with student’s name.)This waiver must be completed and signed by all registrants. You cannot attend the event if we do not have this form. Understanding that the employees of Nipawin Bible College will act according to their best judgment to ensure the health and safety of all participants, I hereby release Nipawin Bible College and all people associated with three60fiveJUNIOR 2017, from legal liability for any injuries or illnesses involving the registrants while at three60fiveJUNIOR 2017. I understand the registrant is expected to conduct him/ herself in a manner conducive for Christian fun and spiritual growth. I accept that the leadership of three60fiveJUNIOR 2017 and Nipawin Bible College reserves the right to correct and/or send a registrant home at his/her own expense. I also acknowledge and agree to allow my name, photograph and/or quotes from the three60fiveJUNIOR 2017 to be used by Nipawin Bible College should they be used in future promotional material. If you are 17 years and under, parent/guardian complete the following:Parent/Guardian/Adult (aged 18+) Name*Check box if as the Parent/Guardian/Adult (aged 18+) named in this document you have read, understand, and will adhere to the contents therein.*I AgreeEmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.