Potential Impact 2017 Information Form

Please note this is a two-part registration. Once completing this form and clicking "submit" you will be taken to the next page for confirmation and payment.

*Denotes Required Field * Title

* First name

* Last name

* CBWC Church Group

* Date of Birth

* Gender

Male
Female

Cell phone number ( ) -

Parent/Guardian Name (For Students Grd 11-12 only)

Parent/Guardian Email (For Students Grd 11-12 only)

Parent/Guardian Phone (For Students Grd 11-12 only) ( ) -

Attendee's Home Address

Parent/Guardian Home Address(if different than student home address)

* Emergency Contact Name

* Emergency Contact Phone ( ) -

* Medical Concerns?

* Medical Card#

* Out-of-Province Insurance Carrier

* Out-of-Province Insurance#

* Out-of-Province Insurance Card-holder Name

Would you like to be added to CBWC's emailing list?

Do you need transportation from the Edmonton airport? If so, when?

I have understood that I need to follow the link provided after submitting this form to complete step two with payment in order to complete my registration.