Encounter Application — Harvest Assembly

Application for Encounters

Are you attending the Men's or Women's Encounter?

CONTACT

Name

Applications 16-17 years of age must have a parent/guardian complete the Release Form (below) and Medical Release (below).

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

CHURCH INFORMATION

Do you consider Harvest your Home Church?

Yes

If not, what is your Home Church, if you have one?

If you attend another church, your Pastor must sign the Pastoral Blessing Form (see instructions below).

Is this your first Harvest Encounter?

Yes

If yes, how many times have you attended?

FINANCIAL DETAILS

The cost of the Encounter is $100. 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?

Yes

If yes, please explain the situation and need

If Financial Assistance is requested, how much are you able to pay toward the cost?

Please submit your portion to the Church Office via check (see check instructions under Financial Details).

SIGN AND DATE

Please Type Your Full Name

This will be considered an Electronic Signature.

Date

YYYY

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

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Age

Parent's Name

Phone

(###)

###

####

Parent's Encounter Date

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.

Family Physician

Physician Office Phone

(###)

###

####

Parent/Guardian Signature

Please type your full name. This will be considered an electronic signature.

Date

YYYY

Specific Medical Needs (Allergies, Medications, etc.)

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.

Application for Encounters

Where & When

LOCATION

OFFICE HOURS

SERVICE TIMES