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Rough Itinerary

This trip is for Rising 8th - 12th Grade Students (24-25 School Year)

Use the form below to register for our Mini Urban Adventure from September 13-15, 2024. Registration closes on August 28, 2024.

STUDENT INFORMATION

Student First Name*

Student Last Name*

Preferred Pronouns

Birthday*

Month

Day

Year

Student Phone #

T-Shirt Size

HEALTH & EMERGENCY INFORMATION

Medications

My student will require medications to be administered during the trip.

If YES, please list all medications, what the medication is for, dosage, and administration instructions below:

Medication 1 Name

For:

Dosage (mg, mL, etc.)

Administration Times / Instructions:

Medication 2 Name

For:

Dosage (mg, mL, etc.)

Administration Times / Instructions:

Medication 3 Name

For:

Dosage (mg, mL, etc.)

Administration Times / Instructions:

Medication 4 Name

For:

Dosage (mg, mL, etc.)

Administration Times / Instructions:

If your student has more than 4 medications, please contact Amber Cotton so that a full list can be provided.

Conditions

Allergies?

If YES, please list and describe the type of reaction to all allergens:

Asthma?

If YES, please list any triggers and/or signs that the leaders should be aware of:

Diabetic?

If YES, list medications required:

Emotional or Psychological Conditions?

If YES, please describe:

Heart Condition?

If YES, please describe:

Seizures?

If YES, please describe:

Hearing Impairment?

Vision Impairment?

Physical Activity Restrictions?

If YES, please describe:

Insurance Information

Insurance Provider:

Policy Owner Name:

Policy Owner's Birthdate:

Relation to Student:

Policy Number:

Group Number:

GROWN-UP INFORMATION

Grown-Up 1 First Name*

Grown-Up 1 Last Name*

Grown-Up 1 Phone #*

Grown-Up 2 First Name

Grown-Up 2 Last Name

Grown-Up 2 Phone #

EMERGENCY CONTACT INFORMATION

I hereby give permission to St. Margaret's Episcopal Church and the adult chaperones on the trip to take any and all appropriate actions in the event of an emergency situation involving my child. Every effort will be made to contact me, the parent/guardian, as soon as possible.

In the event that I cannot be reached, I authorize the following individuals to be contacted:

Emergency Contact 1 Name:

Relation to Student

Phone #

Emergency Contact 2 Name:

Relation to Student

Phone #

Grown-Up 1 Signature*

Sign in the box or use the keyboard to type.

Signature field is empty.

By signing above, I acknowledge that I have provided accurate contact, medical, and emergency contact information and consent to the above terms.

PAYMENT

Urban Adventure$150

Sponsor Another Student*$150

Want to help donate to offset the cost of the hotel?

$10

$25

$50

The addition of the hotel would technically increase each student's cost to $325.00. But given the timing, we are keeping the cost as originally planned and asking that anyone who is willing/able to help us offset the cost do so using the donation field above. Thank you for your generous support!

*The "Sponsor Another Student" option is intended for those who wish to donate the cost of registration for another student. If all received donations are not needed, they will be applied to the hotel cost. If we meet our goals with that-- any remainder will be applied to the account for use toward the Youth budget.

If you are in need of financial aid for this trip or any other youth events, please contact Amber Cotton.

ST. MARGARET'S EPISCOPAL CHURCH

606 Newnan Street | Carrollton, GA 30117 | 770-832-3931

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Keep Scrolling for Registration Form!

Click Here to See A Rough Schedule!

This trip is for Rising 8th - 12th Grade Students (24-25 School Year)

Keep Scrolling for
Registration
Form!

Click
Here
to
See
A
Rough
Schedule!