Youth Convention 2023
Please fill out this form and click submit.
Name
*
Date of Birth
*
Allergies/Medical Conditions
*
Please select home church
*
Please select one option.
Sioux Falls
Pierre
Blackhawk
Watertown
Aberdeen
Mitchell
Huron
Webster
Brookings
Milbank
White Clay
Other
Do you have pastoral approval to attend?
*
Please select all that apply.
Yes
No
Emergency Contact Phone
*
Parent/Guardian Name (if under 18)
*
Email (use parent's if under 18)
*
This address will receive a confirmation email
Phone
*
Payment
Register and Pay Online ($75.00)
Register and Pay ($75) at Door ($0)
Register and Pay Online ($75.00)
Register and Pay ($75) at Door ($0)
Amount
Consent and Acknowledgement
*
Please select all that apply.
I hereby give my approval for my child's participation in any and all activities related to South Dakota Youth Convention.
I assume all risks and hazards incidental to the conduct of the activities, and release, absolve, and hold harmless SDYM and its respective representatives from any and all liability.
n the case of injury to said child, I hereby waive all claims against SDYM, including all affiliates, all participants, sponsoring agencies, advisers, and owners and lessors of premises used to conduct the event.
Medical Release and Authorization
*
Please select all that apply.
I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency.
Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and related procedure for the named child, in the event of an emergency
Permission is also granted to SDYM and its affiliates to provide the needed emergency treatment prior to the child's admission to the medical facility.
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
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DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
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NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
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VT
WA
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WV
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YT
Submit
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