2020 E.L.E.C.T. Teen Summit

2020 E.L.E.C.T. Teen Summit Registration Form

Please fill in the form below.
Student Name*

PrefixFirst NameLast Name
Parent Name*

PrefixFirst NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone *

Area CodePhone Number
Cell Number*

Area CodePhone Number
Child's Number*

Area CodePhone Number
E-mail*
Does your child have any allergies or medical conditions we should be aware of? This includes food allergies, medicine, asthma, behavioral, etc. This information will be confidential. This is to help us be aware.
We will use a charter bus to take the field trip. Do you give permission for your child to ride the charter bus?
YesNo
CCDN will end the 2019 E.L.E.C.T. Teen Summit with a field trip to Sparetime in Trussville, AL. Do you want your child to participate?
YesNo
I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in all activities conducted by Community Care Development
I understand

YesNo
TRANSPORTATION RELEASE

Applies to students only I give permission for my youth to be transported to and from, Community Care Development Network sponsored activities in a church, rental, or private vehicle. I understand that parents are responsible for picking students up from the main facility by the designated pick up time.
I understand

YesNo
DISCIPLINE RELEASE

Applies to students only In the event of misconduct, I authorize the staff to send my student home at my expense.
I understand

YesNo
INSURANCE RELEASE

Applies to all traveling I realize the Community Care Development Network’s insurance begins where the individual health and accident policy terminates. It is only valid when all other insurance has been extended to its limits.
I understand

YesNo
PERSONAL BELONGINGS RELEASE

Applies to all traveling I realize that the Community Care Development Network or its sponsors are not responsible for personal belongings.
I understand

YesNo
Photography Release

I grant to [insert organization], its representatives and employees the right to take photographs of me and my property in connection with the above-identified subject. I authorize Community Care Development Network its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Community Care Development Network may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as news, publicity, illustration, advertising, Social Media, and Web content.
I understand

YesNo
GENERAL RELEASE

Applies to all traveling The undersigned or a member of the immediate family of the undersigned realizes that the participant may incur personal injury or bodily damage while participating in such activities, and acknowledge that the Community Care Development Network, it’s officers, directors, employees, agents, or any other parties volunteering on behalf of the organization, shall be held harmless from all actions, claims, costs, expenses or damages of any kind, growing out of or related to any activities of the church. The undersigned or a member of the immediate family of the undersigned further acknowledge this is a full and complete release for all injuries and damages which the participant may sustain as a result of participating in any activity. I, am the legal guardian of the child mentioned in this application and give my permission for him/her to participate in CCDN sponsored activities.
I understand

YesNo
Pay Here for 2020 Teen Summit
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2019 E.L.E.C.T. Teen Summit$20.00
2020 E.L.E.C.T. Teen Summit CCDN Annual E.L.E.C.T. Teen Summits focus on building teens up through youth asset development, encouragement, mentoring, life transition planning, college prep, and goal setting & execution activities. Our group leaders and mentors provide them with alternatives to problem-solving, enrichment, and life skills planning. E.L.E.C.T. Teen Summit Elevating Life Expecting Change Together

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2020 E.L.E.C.T. Teen Summit Registration Form