Courage Quest 2021 Registration Name of Parent/Guardian Completing Registration* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Daytime Phone Number*Alternate Phone Number*Please give us an alternate phone number in the event we are unable to reach you on the number listed above.Parent/Guardian Email Address* Enter Email Confirm Email Name of Parent/Guardian Attending Retreat* First Last Name of Second Parent/Guardian Attending RetreatOnly one parent/guardian has to attend, but both are welcome. First Last Emergency Contact Name First Last Emergency Contact Phone Number*First Child's Full Name* First Last First Child's Preferred Name on Name Tag First What grade is your first child currently in?*First Child's Date of Birth* MM DD YYYY What is your first child's gender?*MaleFemaleSecond Child's Full Name First Last Second Child's Preferred Name on Name Tag First What grade is your second child currently in?Second Child's Date of Birth MM DD YYYY What is your second child's gender?MaleFemaleDo(es) your child(ren) have any allergies, dietary restrictions, or challenges?*YesNoPlease describe your child(ren)'s allergies, dietary restrictions, or challenges.*Do(es) your child(ren) have any special needs or medical/educational challenges we should take into account?*YesNoPlease describe your child(ren)'s special needs or medical/educational challenges.*Note: Please call the church office at 703-978-8724 if you or your child will need assistance during any of the camps.May we take photos of your child(ren) for use in publicizing church events?*YesNoIf you are not currently receiving emails from St. Stephen's Children's Ministry, are you interested in receiving email updates about future St. Stephen's Children's Ministry events?*YesNoAre you willing to volunteer during the retreat?*YesNoAre you willing to help with preparation for the retreat?*YesNoHow would you like to pay?*Registration is not confirmed until payment is completed. There are a limited number of partial scholarships available. If you select "Pay now with a credit card" you will be directed to PayPal to complete payment when you click "Submit."Pay now with a credit cardPay later with cash or checkI am interested in a scholarship.How many people (parents and children) are you registering?* Price: $10.00 Quantity: Cash or Checks must be mailed or directly turned in to Karen Wells in the Church Office. Please include a printed copy of your registration confirmation to assist in matching payment to the correct child. Do NOT place money for Courage Quest in the collection plate.There are a limited number of partial scholarships available on a case by case basis. Pastor Jiyeon will be in touch to discuss specifics.PhoneThis field is for validation purposes and should be left unchanged. Like
