Youth Edge Oct 17 -19 | Delburne Gospel Church

Name (Required)

Email Address (Required)

Note: Payment for this trip is not required until October 13th.

Who is filling out this form?

Phone number of the person filling out the form?

Birthday of Participant

Gender

T-Shirt Size

Roommate request

Provincial Health Number

Medical Information / Allergies

Include special dietary needs

Permission to Administer Medication

Do you give Millar staff or Delburne Gospel Church staff permission to administer medication to your child when necessary?

Emergency Contact Name

Emergency Contact Number

Grade as of fall 2025

School attending

Parent's/Guardian's Name Giving Consent

Consent for Publications

I give my consent to Millar College of the Bible and Delburne Gospel Church to use personal photographs and written testimonials in its publications, including posting on the website, for information and promotion of the college.

Waiver and Parental Consent

As parent/guardian, I hereby authorize Millar College of the Bible and Delburne Gospel Church to act for my child according to their best judgment in any emergency requiring medical attention and I hereby waive and release Millar College of the Bible and Delburne Gospel Church from any and all liability for any injuries or illnesses incurred while at Youth Edge. I have no knowledge of any physical impairment that would be affected by the student's participation in Youth Edge. I consent to my child’s participation in this overnight event at Millar College of the Bible.