Portal | Elevate Individual Registration

Elevate Youth Convention 2024

Individual Registration

IMPORTANT: Prior to completing this form make sure you have your health insurance information available and your waiver form ready for upload.

Tip: Each time you press the Next button on this registration form your information will be saved. This means you can come back to this form at anytime and continue completing your registration. Once you have hit the Submit Form button, please reach out to the registrar team at ycregistrar@clba.org to make any changes to your registration.

First Name

Last Name

Gender

Male

Female

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Personal Email

Church Email

Birthday

High School Graduation Year

Home Church (please include name & location)

T-Shirt Size

Emergency Contact Information

Emergency Contact #1

First Name

Last Name

Relationship to Attendee

Phone/Mobile #1

Phone/Mobile #2

Emergency Contact #2

First Name

Last Name

Relationship to Attendee

Phone/Mobile #1

Phone/Mobile #2

Health Insurance

Insurance Company Name

Insurance Policy #

Name on Insurance Policy

Medical Information

Describe the condition and the severity (including allergies):

List allergies to all medications:

Date of last Tetanus Immunization

Date of last Physical Exam

Any significant changes since last physical exam?

Is the Convention participant allowed to receive Benadryl:

Physician Information

First Name

Last Name

Phone/Mobile

Waiver Information

Please use the button below to upload completed waiver information.

File Upload (you can upload a picture or PDF)

Choose File