2017 NATIONAL BIBLE QUIZ FINALS - AG

1 2017 NATIONAL BIBLE quiz FINALS . GENERAL INFORMATION & PAYMENT form . The final registration postmark deadline for all Participants and Officials is May 24. Visit for more registration information and tools. PLEASE KEEP THIS SHEET FOR YOUR RECORDS. DO NOT RETURN TOP HALF WITH form . Mail completed registration form with payment via certified mail to: NATIONAL youth ministries, ATTN: NBQF, 1445 N. Boonville Ave., Springfield, MO 65802. -or- Fax with credit card payment to: , ATTN: NBQF. - The NATIONAL office is not responsible for lost, stolen or destroyed mail. For your protection, obtain insurance for, and retain all records of, mailed registration forms and fees.

2 - Please allow 28 days for processing. Children 10 and under are free but do require a registration form . Please read the form carefully and thoroughly before submitting. If you have any questions regarding your registration, please contact the NATIONAL office at or PARTICIPANT REGISTRATION INCLUDES: Access badge and lanyard Thursday night fellowship Official Program Monday Thursday lunches Sunday Night Ice Cream social Friday Banquet (those planning to attend must select this add-on ticket on the registration form ). OFFICIAL'S REGISTRATION INCLUDES: Access badge and lanyard Thursday night fellowship. Official Program Friday banquet (those planning to attend must Sunday Night Ice Cream Social select this add-on ticket on the registration form ).

3 GENERAL ATTENDEE'S REGISTRATION INCLUDES: Access badge Friday night banquet (those planning to attend Lanyard must select this add-on ticket on the registration Program form ). Monday Thursday Lunches ADD ON TICKETS. Each registration type comes with a variety of add-on tickets. Please check all that apply to you to ensure accurate registration. If you have questions about which tickets may apply to you, please call ext. 4041 or e-mail PAYMENT INFORMATION. NYM/NBQ does not refund cancellations for any registrants (neither General Attendees, Officials nor Participants). Funds may be transferred to substitutes/new registration. Payment must be included w/ registration form (s).

4 Please list all registrants covered by this payment: Pay to: AG Youth Ministries If more room is needed, please attach a typewritten sheet. All Check Number _____ registrants (Participants and General Attendees) must include a Money Order Number _____ complete form with this payment. Credit Card Name: _____ Name Amount Billing Address: _____ _____ _____. Card Number: _____. _____ _____. Expiration Date: _____. Phone Number: _____ _____ _____. _____ _____. Total Amount: _____ _____ _____. One check, money order or credit card payment may be sent to cover multiple _____ _____. registrants. If registrants are paying separately, please send one payment slip for each payment made.

5 _____ _____. _____ _____. Cardholder: _____ _____ _____. Signature Date _____ _____. _____ _____. _____ _____. Church Name: _____. 2017 NATIONAL BIBLE quiz FINALS . PARTICIPANT REGISTRATION form . Each individual registrant (Participants, Officials and General Attendee) must fill out his/her own form Please print clearly with blue or black ink Fill out ALL sections COMPLETELY. EVENT REGISTRATION AND ADD-ONS. PARTICIPANT: GENERAL ATTENDEE. (Includes registration, program, four lunches, OFFICIAL (includes registration and program only). banquet, and event t-shirt) Add-on: Event T-shirt ($15) (fill out only). Head Coach ($165) Add-on: Monday Lunch ($0) Parent/Adult/Minor 11- 17($15).

6 Assistant Coach ($165) Add-on: Tuesday Lunch ($0) Child 5 - 10 ($0). 1 v. 1 Quizzer ($165) Add-on: Wednesday Lunch ($0) Add-on: Event T-shirt ($15). Teen Team Quizzer ($165) Add-on: Thursday Lunch ($0) Add-on: Monday Lunch ($15). Add on: I am a Senior Quizzer ($0) Add-on: Friday Banquet ($0) Add-on: Tuesday Lunch ($15). Add On: Senior Shoot Out ($0) Add-on: Wednesday Lunch ($15). Add On: Friday Night (June 30, 2017 ) Add-on: Thursday Lunch ($15). Pizza Party (0$) Add-on: Friday Banquet ($40). Add-on: Child 5 -10 Friday Banquet ($20). Add-on: Child 0 - 4 Friday Banquet (0). TOTAL INDIVIDUAL REGISTRATION FEE: _____. (Neither AG Youth Ministries or NBQ offer refunds on cancelled tickets.)

7 REGISTRATION INFORMATION REQUIRED (ALL REGISTRANTS). Name: _____ Grade: _____ DOB: _____ T-Shirt Size: _____. First Last 2016/ 2017 mm/dd/yyyy S, M , L, XL, 2XL, 3XL. Mailing Address: _____. Number Street Apt. City State Zip Phone Number: _____ Email Address: _____. ###-###-#### This is required for individual confirmation I do not give permission for the personal information above to be given to any AG institution, school, ministry other than AG Youth Ministries. CHURCH AND TEAM INFORMATION REQUIRED (ALL REGISTRANTS). Name: _____. Official Church/Organization Name City State Senior Pastor First & Last Name TBQ Team Name: _____ Region: _____. Head Coach Name: _____ Phone: _____ Email: _____.

8 First Last ###-###-#### For group confirmation and receipts Mailing Address: _____. Number Street Apt. City State Zip Assistant Coach #1: _____ Assistant Coach #2: _____. First Last First Last RISK ASSUMPTION, MEDICAL RELEASE AND LICENSE REQUIRED (ALL REGISTRANTS). I, the registrant named above or parent/legal guardian thereof, assume full liability of hazard and risk for myself (or my child) during BIBLE quiz Nationals 2016. I give permission for hospital or emergency medical staff to administer any necessary treatment to me (or my child) should I (or he/she) be sick or injured during BQ Nationals 2016 I accept full responsibility to communicate any medications or medical conditions to appropriate medical staff.

9 I understand and agree that neither the NATIONAL Youth Ministries of the Assemblies of God, nor the General Council of the Assemblies of God, or any of their affiliated entities or individuals , directors, officers, employees, agents, volunteers or any other representatives thereof shall incur any financial responsibility of liability whatsoever, for any such injury or damage resulting from my service participation at BQ Nationals 2016 however caused, whether due to negligence or any other acts of any person. *If the emergency contact is not present on-site, it is the parent/legal guardian's responsibility to designate an on-site adult representative to act in case of emergency.

10 Parents, legal guardians, and designated representatives are responsible to have student medical records or knowledge thereof. Designated representatives must carry authorized parental/legal guardian consent in writing. Emergency Contact Name: _____ Phone Number: _____. Authorized on-site representative: _____ Phone Number: _____. REQUIRED SIGNATURES. 1. ALL signatures indicate that you have completely read and understand the BIBLE quiz rules, guidelines, medical release, license, and agree to abide by them. Registrant Signature (ALL Registrants): Pastor Signature (All Participants): _____ _____. Parent Signature (Required if participant is UNDER 18): Coach Signature (All Participants): _____ _____.