171st session of the California-Nevada Annual Conference | June 19-22, 2019 | Modesto, CA

ACS19: Youth and Child Program

Use this form to register your youth or child(ren) for the Youth and Child Program. In order to allow adequate time for background screening, the registration deadline is June 17, 2019. 

(IMPORTANT NOTES):

  • Registration of your youth or child(ren) is required to ensure availability.
  • Before you submitremember to PRINT A COPY OF THE REGISTRATION FOR YOUR RECORDS and bring the copy to conference with you. You will need to sign medical emergency forms when you check your child in at conference.
  • To successfully register, FULL PAYMENT MUST BE MADE AT TIME OF REGISTRATION. Due to the necessary preparations for the program, no walk-in registrations or payments will be accepted on site at ACS. No Exceptions.
  • DEADLINE TO REGISTER: June 17, 2019

* Denotes required field.

Name and Email of Parent/Guardian:
First Name
Last Name
Email
Name of Participant(s):
*First Name *Last Name
*Date of birth:
*Age while at Conference:
*School Grade (Fall 2019):
Anything else helpful for the director to know about your child?

Ex. Special interests, hobbies, etc.

MEDICAL INFORMATION
*Physician Name:
*Physician's Phone Number:
*Preferred Physician or Hospital during ACS:
*Insurance Provider:
Insurance Plan Number:
Subscriber Number:
Please list any special needs:

Ex. Dietary restrictions, medication, allergies, etc.

PROGRAM INFORMATION

Pricing Information:

Fees have been calculated to cover actual costs for a quality program, minus $3,500 subsidy from the Annual Conference. Fees include lunch, snacks, crafts, some field trips for kids and youth, and any extra staff required for the nursery.

FULL PAYMENT IS REQUIRED FOR SUCCESSFUL REGISTRATION OF YOUR YOUTH OR CHILD(REN).

Program Selections for Younger Children: 6 months Old thru Kinder

Check the appropriate boxes according to your desired program needs.

Wednesday (8:15 am to 1:15 pm) ($20)
Wednesday (1:15 pm to 5:45 pm) ($20)
Wednesday (7:00 pm to 9:30 pm) ($15)
Thursday (8:15 am to 1:15 pm) ($20)
Thursday (1:15 pm to 5:45 pm) ($20)
Thursday (7:00 pm to 9:30 pm ($15)
Friday (8:15 am to 1:15 pm) ($20)
Friday (1:15 pm to 5:45 pm) ($20)
Friday (7:00 pm to 9:30 pm) ($15)
Saturday (8:15 am to 1:30 pm) ($20)
Program Selections for Older Children: 1st thru 5th Grade

Check the appropriate boxes according to your desired program needs.

Wednesday (8:15 am to 1:15 pm) ($20)
Wednesday (1:15 pm to 5:45 pm) ($20)
Wednesday (7:00 pm to 9:30 pm) ($15)
Thursday (8:15 am to 1:15 pm) ($20)
Thursday (1:15 pm to 5:45 pm) ($20)
Thursday (7:00 pm to 9:30 pm ($15)
Friday (8:15 am to 1:15 pm) ($20)
Friday (1:15 pm to 5:45 pm) ($20)
Friday (7:00 pm to 9:30 pm) ($15)
Saturday (8:15 am to 1:30 pm) ($20)
Program Schedule for Youth: 6th thru 12th Grade

Check the appropriate boxes according to your desired program needs.

Wednesday (8:15 am to 1:15 pm) ($20)
Wednesday (1:15 pm to 5:45 pm) ($20)
Wednesday (7:00 pm to 9:30 pm) ($15)
Thursday (8:15 am to 1:15 pm) ($20)
Thursday (1:15 pm to 5:45 pm) ($20)
Thursday (7:00 pm to 9:30 pm ($15)
Friday (8:15 am to 1:15 pm) ($20)
Friday (1:15 pm to 5:45 pm) ($20)
Friday (7:00 pm to 9:30 pm) ($15)
Saturday (8:15 am to 1:30 pm) ($20)
PARENT/GUARDIAN INFORMATION
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Primary Phone:

This phone number will be the primary number used in case of emergencies.

Secondary Phone:

This phone number will be the secondary number used in case of emergencies.

*Email Address:
HOTEL INFORMATION
Hotel:

May be filled out at Conference.

Hotel Room Number:

To be filled out at Conference.

Hotel Phone Number:

To be filled out at Conference.

PERMISSIONS:
Name(s) of other adults who are authorized to sign your child(ren)/youth in & out:
*Photo Release:

I give permission to allow photographs and/or video of my child/youth taken during the 2019 Annual Conference Session, June 19 - 22, 2019 to be used in conference publications, news releases, social media, online, and in other communications related to the mission of California-Nevada Annual Conference.

Yes
No
*Field Trip Permission:

I give permission for my child/youth to attend field trips and activities at the 2019 Annual Conference Session, June 19 - 22, 2019. I understand this includes permission for children and youth (grades 1-12) to ride in insured vehicles with insured drivers or on public transportation. 

Yes
No
*Medical Emergency Permission:

In case of emergency and in the event that I am not readily available, I/we give permission for the Annual Conference Childcare staff to obtain emergency medical treatment for my/our children.

Yes
No
*Parent/Guardian Signature:

Enter your name below. By typing your name and signing in the area below you are verifying your name and date of this signature

Draw your signature below.
clear signature
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