CIY MOVE 2020 1Information2Payment Student's Name* First Last Student's Cell Phone*If your student doesn’t have a cell phone, enter yours!Parent's Name* First Last Parent's Cell*Parent's Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Grade*Choose the grade your student is CURRENTLY in.9th Grade Guys9th Grade Girls10th Grade Guys10th Grade Girls11th Grade Guys11th Grade Girls12th Grade Guys12th Grade GirlsMedical Release*Check the box below to certify your student has an up-to-date medical release form on file. If you need to submit a new/updated medical release form click here to fill out the form electronically and then return to this page to finish registration. I certify that my student has an up-to-date medical release form on file Payment Options:*On the Thursday we’ll be at CIY, we’ll have the opportunity to have a group outing. We will be participating in a white water rafting experience that has extra cost ($40). We HIGHLY RECOMMEND that your student participates in this with us, however, we want there to be an option for those who aren’t comfortable participating. Students who don’t participate will have the option to play board games on campus with some leaders. If you select one of the deposit options, please keep in mind that this is a non-refundable deposit! Deposit for CIY Move + White Water Experience ($150 Non-Refundable) Deposit for CIY Move ($150 Non-Refundable) CIY Move + White Water Experience ($480 Non-Refundable) CIY Move ($440 Non-Refundable) Do you have a coupon code?* Yes No Coupon Code* Would you like to contribute toward another student’s cost for this event?Enter any dollar amount to contribute Total $0.00 Credit CardCard Details Cardholder Name CommentsThis field is for validation purposes and should be left unchanged. Δ
