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					                              Seven seas & Huff Hills, Mandan, ND - January 1-3, 2009
                               Cost: $85 per person    Deadline: December 20, 2008!
                             This non-refundable fee includes admittance to all activities.
                                                    REGISTRATION FORM
Name: ________________________________________ Birth date: _________________Grad Yr: ______ [ ]Male                           [ ]Female

Street Address: _________________________________________________________Home Phone (                       ) ____________________

City: ____________________________________________ State: ______________________ Zip Code: ____________________

District: _________________ Church: __________________________________ E-mail: _________________________________

 Bible Quizzing:
       [ ] Quizzer
                                                                    Talent:     [ ] Junior High     [ ] Senior High
                                                                    Were all pieces performed/displayed in local church         [ ] Yes [ ] No
       [ ] Coach                                                    [ }ART: (1entry = 1 event)
                                                                      [ ] Category:__________________________________________
                                                                      Name of Piece:_________________________________________
 Athletics: [ ] Junior High [ ] Senior High                         [ ]VOCAL
      [ ] SH Men’s Basketball [ ] A Team [ ] B Team                   [ ] Solo [ ] Male [ ] Female
      [ ] JH Men’s Basketball                                         [ ] Small Ensemble (2-4) [ ] Large Ensemble (5 & up)
                                                                      Group Name:__________________________________________
      [ ] Women’s Basketball (5on5)                                   Name of Piece:_________________________________________
      [ ] Three Point Contest                                       [ ]DRAMATIC ARTS                                [ ] CREATIVE ARTS
      [ ] Women’s Volleyball                                          [ ] Original Speech/Oral Interpretation      [ ] Human Video
      [ ] Powerlifting [ ] Men [ ] Women                              [ ] Mime/Drama            [ ] Puppets        [ ] Interpretive Dance
               (Senior High Only)                                     Group Name:__________________________________________
      [ ] Flag Football - 7on7                                        Name of Piece:_________________________________________
      [ ] Soccer                                                    [ ]INSTRUMENTAL
                                                                      [ ] Solo [ ] Ensemble
      [ ] Dodgeball
                                                                      Group Name:__________________________________________
      [ ] Bowling                                                     Name of Piece:_________________________________________
      [ ] Table Tennis                                              [ ]KEYBOARD
      [ ] Skateboarding                                                [ ] Solo [ ] Ensemble
                                                                       Group Name:__________________________________________
                                                                       Name of Piece:_________________________________________
                                                                    [ ]ORIGINAL COMPOSITION
 JUNIOR HIGH -- 6th - 8th Grade                                        [ ] Vocal         [ ] Instrumental        [ ] Creative Writing
                                                                      Name of Piece: ________________________________________
 SENIOR HIGH – 9th thru 12th Grade                                  [ ]WORSHIP BAND
                                                                       [ ] Group Name: ______________________________________
                                                                       Name of Piece:_________________________________________
                                                                    [ ] Video Production
                                                                    [ ] Web Design




                                                      RULES
1.   All registrants must follow the schedule and curfews set by the DKX leadership team.
2.   I agree to abide by all guidelines and policies of the Dakota NYI for DKX and also agree to conduct myself in a manner that
     pleases God, my family, and my church.
I agree to these statements and guidelines and all others set forth by the Dakota District NYI.

REGISTRANT’S SIGNATURE__________________________________________________________



                                                       Remember:
                                      1.) Registration Deadline is: December 20, 2008

                                        2.) Make your checks to: Dakota District NYI

                                                  3.) Mail this form & check to:

                                               Living Hope Nazarene Church
                                                                th
                                                       1826 N. 8 St
                                                    Bismarck, ND. 58501
                                AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

I, ________________________________, of _______________________, ________________________
          (Name of parent or guardian)                        (City)                                   (County)

________ am the [ ] father, [ ] mother [ ] legal guardian (check one) of ____________________________
(State)                                                                                                (Name of minor child)

a minor of ________________________________, _____________________, _______ of whom I have full
                    (City)                                              (County)                       (State)
custody and control, who will be attending DKX at Seven Seas & Huff Hills, City of Mandan, County of
Morton, State of North Dakota.

        I consent to the necessary medical and/or dental treatment, including the decision for hospitalization,
and if necessary, surgery, herby authorizing the Dakota District Nazarene Youth International or
Pres. Eric Bonness or other assigned leadership or administrator of the Dakota District NYI to secure the
necessary medical or dental treatment for said minor and to receive any necessary assistance.

       The following information is given relative to said child’s medical history:
Allergies:________________________________________________________________________________
Medications being taken:____________________________ Date of Last Tetanus shot:__________________
Physical Impairments:______________________ Other pertinent facts to which physicians should be alerted:
________________________________________Insurance Company:________________________________
Policy Number:____________________________ Dated this ____________ day of ______________(month)
20_____ at _______________________________________________________________________________
                                          (City and State)


Signature of parent or guardian:_______________________________________________________________

                                               RELEASE OF ALL CLAIMS

Release made this ______ day of ___________, 20____ by ________________________________________,
                        (Day)             (Month)            (Year)                (Name of Parent or Guardian)

of ____________________________________________, ______________________________, __________
          (City)                                                                   (County)                                    (State)

as [ ] parent [ ]legal guardian (check one) of ___________________________________________________
                                                              (Name of Minor child)

I hereby release and discharge Dakota District Nazarene Youth International and, its agents, executors,
administrator, or assigned employee, of any claim against Dakota District Nazarene Youth International, its
successors or assigned employee, for all personal injuries, known or unknown, and injuries to property, real or
personal, caused by or arising out of, the above described DKX to be held at the Sleep Inn & Waterslides and
the surrounding area.

I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with full know-
ledge of its significance. I have executed this release as parent or guardian of the above child as stated above.


Signature of parent or guardian:______________________________________________________________

				
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