Please fill in all the fields below.

First Name


Surname
Gender
Date of birth
Mobile Phone
Daytime Phone
Email Address
Street Address


Suburb


State


Postcode
 
Church Name
If CityLife Church is your home church, which site do you attend?
Life Group leader's name
What year level are you in at school?
Which campsite are you registering for?
 
Are you on any medication?
Do you suffer from any medical conditions?
Do you have any dietary requirements?
Do you suffer from any of the following
Please note if you have indicated that you suffer from asthma and/or anaphylaxis you will need to submit the relevant plan with your parental consent form.

 
Please provide the name and number of an individual we can contact in the unlikely event of an emergency.

Emergency contact name
Emergency contact phone number
Please charge my VISA/MasterCard credit card with: AU$
(Super Early Bird rate is $175.00 per registration.)
Name on Card *
Card Number *
Expiration *
Card Security Code *

Terms & Conditions
All information submitted in this form will be handled in accordance with the CityLife Church Privacy Policy. For more information see http://www.citylife.church/privacy/.  No GST has been charged for this event. Should you find yourself unable to attend after registering, please contact the youth staff on 9871 8300 or via youth@citylife.church to arrange a refund or transfer of registration.

By taking part in this event, you give CityLife Church permission to take and use images and/or footage of me/my child at this event and for EPIC Youth related events through until July 2020 for promotional purposes.


   


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