The FAMiLY Leader

LEAD Worldview Weekend Registration Form

LEAD Registration for 1 Student$100.00

Qty

Student Information

First Name

Last Name

Male/FemaleMaleFemale

Grade In Fall

Student Full Address

Student's Phone Number

Student's Email

Church Name

Church City

School Name

Have you Attended LEAD Before?YesNo

How did you hear about LEAD?/Who referred you to LEAD?

Parent Contact Info

First Name

Last Name

Address 1

Address 2

Postal Code

City

State/Province

Cell Phone Number

Email Address

Second Parent Contact Info

First Name

Last Name

Cell Phone Number

Please download/view documents and agree by checking boxes

2023 Worldview Weekend WaiverI have read and agreed

Medical ReleaseI have read and agreed

Student CovenantI have read and agreed

Policies and ProceduresI have read and agreed

Health Information & Medical Release Form

Physician's Name

Physician's Phone

Health Insurance Carrier

Policy/Group #

HMO/PHP auth Phone no.

Current Medications will be self-administered. Please list ALL current medications, including over the counter, and dosages. If necessary, medications can be refrigerated in the LEAD office. It is acceptable for students to keep their medications in their dorm rooms.

Do you need to refrigerate your medications in the LEAD office?NoYes

List all allergies:

Are any allergies you have airborne?NoYes

If YES, please indicate which allergy is airborne.

Please list all medications you have a reaction to:

Please list all food you have reactions to:

Please list all plants you have reactions to:

Please list all animals/insects you have reactions to:

Are there chronic problems or illnesses not indicated above? (If yes, please list them)

Are all immunizations up to date?

Date of last Tetanus Booster:

Does your child have any special dietary needs/restrictions? (If yes, please specify)

Regarding food allergies, items with possible allergen-containing ingredients are labeled or otherwise identified; however, there is always a risk of contamination. There is also a possibility that manufacturers of the commercial foods used could change the formulation at any time, without notice. Participants concerned with food allergies need to be aware of this risk. Neither Faith Baptist Bible College nor TFL will assume any liability for adverse reactions to foods consumed or items one may come in contact with during the week of participation. TFL will do what it can and within reason to accommodate the special food needs of allergic students. To allow time for possible accommodations, TFL must receive a doctor’s notification at least one week prior to the start of the program of a participant's allergies and special needs requests

Anything else we should know?

Payment

Card Number

Card Type

Expiration Month

Expiration Year

Name On Card

CVV Code

Account Number

Routing Number

Name On Account

Account TypeCheckingSavings

Billing Address 1

Billing Address 2

Billing Postal Code

Billing City

Billing State

Billing Country