One per individual and Please Print
______________________________________________________
Email Address
______________________________________________________
Name
______________________________________________________
Mail Address
______________________________________________________
City
State
Zip
______________________________________________________
Phone
Age (16 and up)
______________________________________________________
Name of your Church
______________________________________________________
Church Mail Address
______________________________________________________
City
State
Zip
______________________________________________________
Name of Dance Ministry
______________________________________________________
Pastor Name(s)
(Please
choose the category below that best describes your ministry)
___Worship Dance ___Praise
Dance ___Mine
____Flags
Number of leader attending________________________________
Number of dance team attending___________________________
If you would
to purchase a Conference T-shirt please add $8.50 to your registration mark your size ~
S_____ M_____
L_____ XL____
RELEASE FORM
September 6, 2010
I release, and hold
Harvest Tine Church, Ezekiel Dance Ministry, the Faculty, their agents, and staff harmless from any and all liabilities while
participating in any and all activities at the 2010 Summit.
I understand that I am responsible for any
and all charges as a result of such care or medical treatment.
The legal parent
/ guardian must sing if the participant is under 18 years of age.
(One per individual
and Please Print)
________________________________________________________________________
Applicant Name
(please print)
Date
____________________________________________________
Applicant Signature
____________________________________________________
Parent/Guardian Name (please print)
Date
____________________________________________________
Parent/Guardian Signature
