Name: ______________________________________________ Age: ___________
Address: _______________________________________
City: ______________________ State: ________
Zip Code: ______________ Telephone: ( ) ________ -- __________
Church: ________________________________
Parents: __________________________________________
T-shirt size: S M L XL Insurance: ________________________ Policy Number: ______________________
Code of Conduct
There will be no use or possession of drugs or alcohol at Fall Rally. No smoking will be allowed anywhere during this event. YOU ARE REQUIRED TO PARTICIPATE IN ALL THAT IS OFFERED.
Youth Signature: __________________________________________
Date: __________________
Parent Signature: ___________________________________________
Date: __________________
***Send check payable to NEDCYM for $35 to: Lydia Holmes PO Box 533 Forrest City, AR 72336-0533
