EmailMe Form - 2018 ELCA Youth Gathering

Student Information

Student Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

2017-2018 Grade

School

Birthday

Gender

Home Phone Number

### - ### - ####

Cell Phone Number

### - ### - ####

Email

Parent/Guardian Information

Name

First Last

Home Phone Number

### - ### - ####

Cell Phone Number

### - ### - ####

Email

Address (if different from student)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Fees & Registration

$350 Registration fee is due October 30th, 2017 to reserve your spot with the Saint Luke Youth Gathering group. Additional costs per participant are expected to be about $1,200 for airfare, hotel, additional transportation and meals. Please indicate the portion of this that you are able to provide for your participant. Only Saint Luke Pastors will see your estimate. Providing this information gives us a clear amount of how much we need to fundraise to cover the rest of our costs.

I am able to pay the $350 registration fee in full:

Yes

No

If no, how much could you contribute?

$ Dollars . Cents

I am able to pay the additional estimated $1,200 costs:

Yes

No

If no, how much could you contribute?

$ Dollars . Cents