"*" indicates required fields Event NameEvent Date MM slash DD slash YYYY Membership InformationAre you a registered member of Saint George Church?* Yes No To attend this trip, you or your family must be members of Saint George. Please complete the Online Membership Form. Teen InformationName* First Last Birth Date* Month Day Year Allergies/Food Allergies/Conditions/Medications:Teen Email* Teen Cell #Parents InformationMother's Name* First Last Mother's Cell #*Mother's Email* Father's Name* First Last Father's Cell #*Father's Email* Consent and Payment ProcessingAttendee FeeI give consent for my participation and/or my (above) child’s participation in the Teen SOYO event indicate above. I hereby absolve Saint George Antiochian Orthodox Church of Cicero, IL, the Antiochian Archdiocese, affiliate organizations, employees and representatives, of any liability in the event of accident or injury during my participation and/or my child’s participation in this trip. In addition, I understand I must notify the Teen SOYO advisors and Church staff of any medical history which may cause any harm during my participation and/or my child’s participation in the program. I, also, grant permission for the appropriate use of any photographs, audio recordings, video images, or any other visual or audio reproduction that may be taken of myself and/or my child during this trip to be used in a video, website, social media, for promotional purposes of the program, or shown as Saint George Church sees fit. Furthermore, I understand only proper conduct and behavior befitting the Church will be allowed and disrespectful behavior may result in the dismissal of any person causing misconduct at the cost and responsibility of the said person. Please check the box below to accept consent liability form* Yes, I agreeTotal Due:Please proceed to credit card section to pay this balance. Billing Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card* PhoneThis field is for validation purposes and should be left unchanged.
