Labor Day Family Conference Registration

Primary Contact (must be age 18+)

Full Name*

Cell*

Phone

Email*

Street Address*

City*

State*
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Zip Code*

Church Name

Emergency Contact Information (if single adult)

Emergency Contact Full Name*

Emergency Contact Phone*

Insurance & Health Information

The following information MUST be provided, or a photocopy of both sides of the insurance card included with the registration. Any third party medical treatment will be submitted first to the individual's insurance carrier for payment. Any unpaid or uncovered expenses will then be submitted to FCBC's insurance carrier for payment. Any remaining balance is the responsibility of the individual treated.

Name of Insured (i.e. the name of the policy holder)*

Insurance Company Name*

Insurance Company Phone Number*

Group (If Applicable)

ID Number*

Family Doctor*

List any health needs (Allergies, Heart Disease, Epilepsy, Diabetes, Dietary, Other)

Additional Family Members

How many total family members will be attending?
Single adult2 or 34 or more

Names and age group of additional family members attending (Name / Age Group), if applicable

Age Groups:
Adults: 18+
Teens: 13-17
Youth: 4-12
Children: 3-

Additional Family:

Agreement and Signature

Except as indicated, my family members are in good health and are therefore able to participate fully in activities of the conference. I give my permission for hospital treatment in the event of an emergency, and to release any and all pertinent medical information.

The words "execution," "signed," "signature," and words of like import in this Agreement or in any amendment or other modification hereof (including waivers and consents) shall be deemed to include electronic signatures or the keeping of records in electronic form, each of which shall be of the same legal effect, validity or enforceability as a manually executed signature or the use of a paper-based recordkeeping system, as the case may be, to the extent and as provided for in any applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any other similar state laws based on the Uniform Electronic Transactions Act.

I agree on behalf of my family to the publishing of photos of the conference, which may include images of my family members, with the understanding that such photos will be used solely on the web site, social media, and/or in promotional materials. Photos will not include my name or any other personal information.

I agree on behalf of my family to the disclosure of my personal contact information to French Creek Bible Conference Association staff members and the use of such information by staff members for purposes related to the conferences (e.g. letter writing). I also agree to the disclosure of my personal contact information to the Orthodox Presbyterian Church.

I agree on behalf of my family that any claim or disputes I have or may have with FCBC Association or its staff will be settled by Biblical based mediation and, if necessary, legally binding arbitration in accordance to the provisions of article XII of the bylaws of FCBC Association.

I have fully read and completely understand conference rules and regulations ("Behavioral Agreement") provided by FCBC, and I promise on behalf of my family that we will abide by those throughout the conference.

Signature*

Date Signed*

Payment and Scholarships

Please note there are no scholarships available for the Labor Day Family Conference. Please contact your local church deacons for assistance.

How would you like to pay for conference registration?
OnlineCash or check, in person