Oregon Youth Convention

October 11th - 13th

Student Name
Additional Student Registering (optional)
Additional Student Registering (optional)
Parent/Guardian Name
Parent/Guardian Relationship to Student
Parent/Guardian Phone Number
Parent/Guardian Email


I, the above named parent/guardian, give my permission for all students listed above to participate in the overall activities of the Revive Oregon Youth Convention. I give permission for my student(s) to receive medical attention in the case of an emergency. I/We agree not to hold Bethel Church, its leaders, employees, agents or volunteer staff liable for damages, losses, diseases or injuries incurred during the events by the student(s) listed on this form.
Parent/Guardian Signature

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Payment Details

Cost on or before Sept. 12th:
1 Student $75
2 Students $130
3 Students $180
There is a $35 deposit due at the time of registration. Cost from Sept. 13th - Sept. 26th (last day to register Sept. 26th) add $15 per student to the above cost.
Payment Method
Amount Due to be Paid
Please remember to submit your payment as soon as possible to hold your registration.

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