Repo Uth Outreach

Taking back a stolen generation

Signup Form

Consent Form

If you are interested in going on a trip with us... you must fill out the following form. After filling it out you can simply submit it and it will be emailed to us to put on file for that specific event.
You must fill out a form for each event that you attend!

Student's Information
First Name:
Last Name:
cell phone:
Address:
City:
Zip Code:	(5 digits)
State:
Parent's name
First Name:
Last Name:
Parent Contact Information
Daytime Phone:
Evening Phone:
Email:
Financial Information
Payment Type:
Specific Event:
Personal Information
Age:
Grade:
Allergies:
Current Medications:
Parent Consent:	(signature required)
Other Information
Comments:	Please list any needs or concerns in this box
	I understand that adequate precautions for my child will be taken. I will not hold crossroads Community Church or it’s leaders, nor the staff, nor the staff of repo Uth Outreach, responsible for any accidents. I also give permission for my child to be medically treated in any accidents should arise. (by checking you are agreeing the above info. is accurate)