Name______________________________________

Address____________________________________

City/State/Zip:_____________________________

Phone _______________Cell ________________

Gender: Male______ Female_____

Age: _____________

Grade (in 08/09)___________

Church: ___________________

City/State/Zip:_________________________

Group Leader: Kevin McQuillen

In case of illness or injury, the staff of The Edge Conference is hereby

authorized by me to provide needed medical care and may turn over info

to the insurance company that covers the health of the person mentioned

above. If applicable, I am listing any medical problems or allergies:

________________________________________________________

________________________________________________________

________________________________________________________

Signature of parent or guardian:

____________________________________________