Application for Encounters

CONTACT
Name *
Name
Applications 16-17 years of age must have a parent/guardian complete the Release Form (below) and Medical Release (below).
Address *
Address
Phone *
Phone
CHURCH INFORMATION
Do you consider Harvest your Home Church? *
If you attend another church, your Pastor must sign the Pastoral Blessing Form (see instructions below).
Is this your first Harvest Encounter? *
FINANCIAL DETAILS
The cost of the Encounter is $125. PAYMENTS ARE NON-REFUNDABLE. Please write a check made out to Harvest Assembly, and submit it to the Church Office 2 weeks prior to the Encounter. 525 Kempsville Road, Chesapeake, VA, 23320. Office Hours: Monday - Thursday: 9-4 pm.
Is Financial Assistance needed? *
Please submit your portion to the Church Office via check (see check instructions under Financial Details).
SIGN AND DATE
This will be considered an Electronic Signature.
Date *
Date
ENCOUNTER RELEASE FORM FOR 16-17 YEAR OLD APPLICANT
A parent or legal guardian MUST have attended an Encounter before the child may attend. THIS FIELD DOES NOT NEED TO BE FILLED OUT IF NOT APPLICABLE. PLEASE SCROLL DOWN TO SUBMIT FORM.
Child's Name
Child's Name
Address
Address
Phone
Phone
CHILD MEDICAL RELEASE FORM
I do hereby consent and agree that the above named child may travel to Edge Christian Camp for the Encounter sponsored by the Harvest Assembly of God Church, and I hereby release Harvest Assembly of God Church, its leaders, staff, agents and volunteer assistants from any liability for accidents, illness, or injury which may be sustained by said child during the above mentioned activity. I do further give consent for the leader or properly appointed staff member of Harvest Assembly of God, or their consulting physician to render to my child any emergency treatment, medical or surgical care that might be deemed necessary. Also when necessary for the execution of such care, I grant permission for hospitalization to an accredited hospital.
Physician Office Phone
Physician Office Phone
Please type your full name. This will be considered an electronic signature.
Date
Date
PASTORAL BLESSING FORM
If you attend another church, please contact the front office at mail@harvestva.org or call (757) 547-7717 and we will provide a Pastoral Blessing Form. You will need to obtain a Signature and Date from your Pastor and return it to the Front Office.