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Event Registration
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MSM Fall Lock-in 2024 on Friday, November 1, 2024 @ 6:00 PM
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Price:
16.00
*
Attendee's First Name:
*
Attendee's Last Name:
*
Attendee's Email Address:
*
Attendee's Phone Number:
Country:
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
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British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
China, Hong Kong Special Administrative Region
China, Macao Special Administrative Region
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Cote d'Ivoire
Democratic People's Republic of Korea
Democratic Republic of the Congo
Denmark
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Dominica
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French Southern Territories
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Gambia
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Ghana
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Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
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Holy See
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Hungary
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Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
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Lao People's Democratic Republic
Latvia
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Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
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Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
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Niger
Nigeria
Niue
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Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of Korea
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Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena
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Samoa
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Senegal
Serbia
Seychelles
Sierra Leone
Singapore
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Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
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South Sudan
Spain
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Sudan
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Swaziland
Sweden
Switzerland
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Taiwan
Tajikistan
Thailand
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Timor-Leste
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Turkey
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Tuvalu
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Ukraine
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Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Viet Nam
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Address Line 1:
Address Line 2:
City, State Zip:
AA
AE
AL
AK
AP
AS
AZ
AR
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CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
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NH
NJ
NM
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NC
ND
MP
OH
OK
OR
PW
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PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
Two things to note:
Saturday morning, all families are invited for breakfast at Brader Way, where you'll get to meet your student's small group leader.
We want students to experience as much of the event as they can. If for some reason your student can't participate in the full event, share about those circumstances below so we can arrange for their late arrival / early pick-up time.
Parent/Guardian First Name (2):
Parent/Guardian Last Name (2):
Parent/Guardian Email (2):
Parent/Guardian Phone (2):
Parent/Guardian address (2): If different from above:
*
Approx. how many total family members will join us for breakfast (including this student)?
NOTE
: If registering multiple students, only add family members once.
-- Select --
0
1
2
3
4
5
6+
*
Gender (for sleeping assignments):
-- Select --
Male
Female
Undecided
*
Grade:
-- Select --
6
7
8
*
School Attending:
*
Does this student attend Blackhawk Community Group?:
-- Select --
Yes
No
If so, which Community Group do they attend?:
-- Select --
Brader Way
Fitchburg
Mount Horeb
Waunakee
AASM
If known, who is your student's small group leader?:
Students will spend part of the evening in a small-group "crew." Name up to three friends whose group your student would like to be in,
in order of preference
(we can't guarantee these requests, but we will do our best).
If needed, share about requested accommodations for an early pick-up, non-overnight stay, etc. (Details helpful.):
Help us plan for dinner
- given the following menu options, this student would
probably
choose...
-- Select --
Burger
Bratwurst
Chicken tenders
Veggie burger
HEALTH & MEDICAL INFORMATION
: We collect this information to care well for your student in the event of medical need or emergency.
*
Insurance Company:
*
Account & Group #:
List any food allergies or special dietary needs your student has:
List any other allergies (drug, seasonal, animal, or other) your student has:
*
Will your student carry an epinephrine auto-injector (e.g., EpiPen, Auvi-Q)?:
Yes
No
If yes, where will the auto-injector be kept?:
*
Will your student bring prescription or over-the-counter medications, vitamins, and/or supplements?:
Yes
No
If yes, list all PRESCRIPTION medications your student will take or have available during the event, including dosages and frequency. Indicate “phone call requested” if you prefer to share this information via conversation. (Note: Prescribed medication must be supplied in a labeled container indicating the patient's name, correct dosage, and administration instructions.)
If yes, list all OVER-THE-COUNTER medications, vitamins, and/or supplements your student will take or have available during the event, including dosages and frequency. Indicate “phone call requested” if you prefer to share this information via conversation. (Note: Over-the-counter medications, vitamins, and/or supplements must be labeled with the participant’s name.)
If yes, what is your preference for medication tracking and administration? Students will be allowed to self-administer medication unless you indicate otherwise.
My student can self-track and -administer the medication listed above.
Adult leaders should track and administer the medication listed above for my student.
*
Parent/Guardian Initials:
*
Physical Health: List current or past physical conditions, recent illnesses, or health concerns that could be helpful for program staff to be aware of. Indicate “phone call requested” if you prefer to share this information via conversation. (Note: if your student has a specific medical condition or special consideration that will need monitoring during MSM Lock-In, please email a detailed care plan to msm@blackhawkchurch.org)
*
Mental Health: List current or past mental health challenges your student has had that could be helpful for program staff to be aware of (e.g., depression, bipolar disorder, generalized anxiety disorder, history of psychiatric treatment or hospitalization). Indicate “phone call requested” if you prefer to share this information via conversation
Emergency Contact (If parent/guardians are unavailable)
*
Emergency Contact Name:
*
Emergency Contact Phone:
*
Relation to student:
Promo Code:
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Registration Total:
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