Trinity OPC Fall Youth Rally Registration Form
October 27th-28th
531 Milford Street Easton, PA 18045

REGISTRATION FEE IS $30.00. PLEASE PAY UPON ARRIVAL(CASH/CHECK)
MAKE CHECKS PAYABLE TO: TRINITY OPC

Please fill out a form for each child that you are registering.

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Parent/Guardian Email *
Parent/Guardian Phone: *
Name of Student *
Date of Birth *
Gender *
Address *
Student Email
Home Church *

Allergies/medical conditions that should be known

Current medications being taken

Emergency Contact: Name, Relation to Student, Home Number, Cell Number *

Medical Insurance Information: Name of Insurance, Group ID Number

 *

Doctor/Primary Care Manager Name

 *

Doctor/Primary Care Manager Address

 *

Doctor/Primary Care Manager Phone

 *
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