CIY MOVE 2020 1 Information2 Payment 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?*YesNoCoupon Code* Would you like to contribute toward another student’s cost for this event?Enter any dollar amount to contribute Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.