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For TEC Council Use Only:

United Teens Encounter Christ Weekender Application

Paid $ Check # Date Rec’d

Name:

Date of Birth:

Address: City:

State:

Home Phone:

Cell Phone:

Zip:

Email Address: School:

Graduation Year:

Home Church (Name and City if applicable): Preferred Name/Nickname:

Gender: M / F

T-Shirt Size: Small / Medium / Large / XL / XXL / XXXL Applicant Signature:

Date:

How did you hear about TEC?:

Medical Release Form In the event of a medical emergency, I hereby give my permission to the medical provider selected by United TEC leadership to secure proper medical treatment for my child as named above. I certify that I have read and understand the authorization for medical treatment. I also understand that there is no guarantee or assurance to the results that may be obtained for any such treatment.

Parent or Guardian Signature: Phone: (Home)

Date: (Work)

(Cell)

Email Address: Insurance Company: Policy Holder: ID #:

Group #:

***Please List any special medical or dietary needs in the space below:

PLEASE MAIL COMPLETED APPLICATION AND REGISTRATION FEE OF $65.00** TO: United Teens Encounter Christ Brian and Ashley Anderson 13608 Atrium Ave Rosemount, MN 55068

**Make Checks payable to United TEC Full or partial scholarships are available and can be requested to TEC-Weekenders@comcast.net


Weekender Application