Student First Name *

Student Last Name *

Current Grade *

• 9
• 10
• 11
• 12

Emergency Phone Number *

Student Phone Number

Street Address *

City *

Zip Code *

Birth Date *

Insurance Company *

Insurance Group #

Insurance Policy #

Medical Needs/Allergies

Parent Email Address *

Campus Life Code of Conduct * We desire to provide the best possible atmosphere throughout the trip. Students are expected to cooperate with staff at all times and to participate in all scheduled activities. Possession and/or use of alcoholic beverages and/or any type of drugs is strictly prohibited. Failure to remain within these guidelines is cause for students immediate return home at the parent/guardian's expense. Check this box if you agree and will abide by it.

Disclaimer * I agree not to hold Campus Life responsible for any injury that may result from my son's/daughters participation in CRAIG'S CRUISERS ALL NIGHTER. I also authorize the Campus Life staff to secure any emergency medical treatment necessary during during the trip, and I further assume all responsibility for the decisions so made. I grant permission to Youth For Christ to use or distribute photos or clips that may include, without compensation, for materials created for promoting Campus Life activities.

Parent/Guardian Signature *