Billy Kirk Scholar Day

Student Information

Student First Name

Preferred First Name (Ex: Anthony goes by Tony)

Student Last Name

Birthdate

Student Gender

Are you enrolled in the 21st Century Scholar Program

Yes

I don't know

Email Address

Student Cell Phone

Does Bethel University have permission to occasionally text you?

Yes

Do you give permission for Bethel's AI Assistant to connect with you?

Yes: Emails, Calls, Texts

Yes: Emails Only

No: Emails, Calls, Texts

Mailing Address

Country

Street

City

Region

Postal Code

What size tshirt do you prefer?

Youth Pastor Email
This allows your youth pastor to know that you are on the registration list but does NOT share any of your answers with them

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Type

Parent/Guardian Email

Is this parent/guardian a graduate of Bethel?

Overnight Waiver / Consent

LIABILITY WAIVER

I give my child/dependent permission to participate in an overnight stay at Bethel University. I understand the possible risks associated with such an event, including transportation to and from campus, to which my child/dependent may be exposed. I agree to assume all responsibilities surrounding my child/dependent's participation in this visit. I release Bethel University and its employees against any and all claims, demands and actions which may result from damage to property or personal injury due to my child/dependent's participation in this overnight stay, beyond the control of, and without the fault or negligence of Bethel University or its employees.

MEDICAL CONSENT

I hereby consent for my child/dependent to be given medical treatment as may be deemed necessary by a physician in the event of injury, accident, or unexpected illness. I understand that Bethel University will not be held responsible for any financial obligation incurred related to medical treatment. I understand that an attempt shall be made to contact in such an event.

Please choose how you would like to spend the night.

I plan to spend the night and would you to choose a Bethel Student to host me.

I am making my own arrangements to spend the night with a current Bethel student.

Please list any current allergies/medical conditions that we should be aware of:

Emergency Phone

In place of your signature, please type your first and last name (parent)