CCC's Sign Up for MOVE 2024 
This year we will be in Bowling Green Ohio from June 26th - July 1st. The cost is $375 per student, a $100 deposit is due May 21st. Full payment is due Sunday, June 18th.
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Student's Name *
Student's Birthdate *
Student's Gender *
Guardian's Name *
Email *
Address *
Phone Number *
Secondary Phone Number

If the person(s) named above is not available in case of an emergency, notify (provide full name and number):

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Name and Number of Primary Physician:

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Health Insurance Carrier and Policy Number: 

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Is the student taking any medications?

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Allergies (food, medicines, insects, plants, etc.)

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Any medical conditions we should be aware of?: 

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Do we have permission to give your student over-the-counter pain relievers if needed as evidenced by student’s statement or behavior? 

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COVID-19

In order to send your student to CIY Mix or CIY Move, we ask that you do one of these two things:

1 - Have your student vaccinated

2 - Acknowledge that you agree to come pick up your student if he or she develops symptoms or Is exposed to someone with symptoms while at the event.

COVID-19 Response

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Liability Release

I do hereby release, forever discharge and agree to hold harmless Cicero Christian Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in Church Activities. The undersigned further hereby agrees to hold harmless and reimburse said church, its directors, employees, chaperones, and agents for any liability sustained by said acts of said participant, including expenses incurred attendant thereto.

The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless said church, its directors, employees, chaperones, and agents from failure to act on the part of those chosen to administer medical care on behalf of the participant.

Electronic Signature:

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Date:

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Is there anything else we should know as we care for your student?
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