Online Application Form

*Required Information

Applicant's Name (First Last)*

Birthdate*
19971998199920002001200220032004JanFebMarAprMayJunJulAugSepOctNovDec01020304050607080910111213141516171819202122232425262728293031

Grade*
23456
Sex*
MaleFemale

Street/Mailing Address*

City*

Prov/State* NBNSONQCPEMENH

Postal/Zip Code*

Home telephone*

Mobile telephone

Email

Pastor's Name

Home Church

Name of group of retreaters you will be with:

NBBI student you would like to stay with (if any):

Retreaters you would like to room with (if any):

Medical History
Does your child have any known allergies? (Please check all that apply.)*

 None Bee Stings Penicillin Other drug allergies (Please explain below.) Foods (Please explain below.) Other (Please explain below.)

Additional information on allergies:

Does your child have a history of:

 Asthma Other Respiratory Problems Heart Trouble Diabetes Seizures/Convulsions Appendicitis Bed Wetting Sleep Walking

If any of the above conditions were checked, please explain and indicate the date (month/year) of the last episode in this box:

Date of last tetanus shot (month/year): JanFebMarAprMayJunJulAugSepOctNovDec 199719981999200020012002200320042005200620072008200920102011

Medicare# Prov/State NBNSPEQCONMENH

Insurance Company

Policy #

Subscriber name

In case of emergency please contact:

Name:

Phone 1:

Phone 2:

Parent or Guardian:

By submitting this form, I give permission for the above mentioned applicant to attend NBBI from September 30-October 1, 2011. NBBI has my permission to obtain emergency medical treatment should the need arise.

I agree (please check one)*  Yes No

Name of Parent/Guardian*

Payment:  Visa Mastercard Cheque Other

We must receive your payment to complete this application.
Please call our office as soon as possible to pay by Visa or Mastercard
(506-375-9000, Monday-Friday, 9-5 Atlantic time).
If you pay by cheque, your application will be processed according to the postmark on the envelope.

Before clicking the “SUBMIT FORM” button below please be sure you have fully and accurately completed all areas of the form above. Incomplete or inaccurate submissions will sometimes make it difficult or impossible to finalize your on-line application.

Please type the characters in the above image in the space provided. (Spam Guard)