Personal Information
First Name:
M.I.:
Last Name:
Nick Name:
Address:
 
City, State, Zip:
,
Home Phone:
 ( ) -
Cell Phone:
 ( ) -
Work Phone:
 ( ) -
Email:
Birth date:
 (Enter as MM/DD/YYYY)     Age:
T-Shirt Size:
   
Bethel / Assembly:
Jurisdiction:
   
  Have you ever attended S.L.C. Before?

Location of previous S.L.C.?

   
 

Have you completed the Leadership Correspondence Course?

Which LCC Levels have you completed?
The structure of DeMolay
DeMolay Programming
DeMolay Rules, Regulations, and Policies
The History & Heritage of DeMolay
A Comprehensive Review

   
  Have you completed the Representative Sweetheart Program?

Parent - Guardian / Advisor's Approval
  I have my Parents approval to attend
Parents Name:
Parents Phone:
 ( ) -
  I have my Bethel Guardian/Mother Advisor's Approval to Attend.
Advisors Name:
Advisors Phone:
 ( ) -

Pricing Information

Fees

  • Before or on June 15, 2012 - $195.00
  • On or after June 16, 2012 - $205.00

Fees include: Three nights lodging, 10 meals, Conference T-Shirt, L.C.C. Fees, sporting and water activities.

Payment Info
Check here if you are going to Pay with a Chapter Check:
By not checking the box you are choosing to pay by Credit Card. This payment will be done at Paypal after you have completed the sign up form.

 


Medical History & Release

I understand that while on my way to, in attendance at, and returning from any DeMolay activity, I will fulfill my DeMolay obligations as well as obey any special guidelines of that event. I understand that while I am on the Conference Premises I am not to be in possession of any tobacco substance, D.L.C. is a Non-Smoking Conference. I will not sell, distribute of possess liquor or any illegal drugs.

I have read and will comply with the above statement.

The participant is permitted to participate is ALL S.L.C. activities and events with the FOLLOWING EXCEPTIONS (e.g.: hiking, swimming. If none enter "NONE"):

Be Aware that the participant has experienced the following health problems:

Appendicitis
Hernia
Fainting
Sinus Trouble
Frequent Colds
Epileptic Seizures
ADD 		Cramps in Water
Asthma
Knees
Ear Trouble
Motion Sickness
Heart Trouble
ADHD

Eyes (Needs Glasses)
Diabetes
Throat
Bones (broken, Weak)
Convulsions
Rheumatic Fever
.

Other problems (or "NONE"):

Medication that will be taken at the Conference (or "NONE"):

 

Medical Insurance Company Medical Plan (or "NONE"):
Policy Number(s):
Emergency Contact:
Contacts Phone Number:
 ( ) -
 

As the Parent or Legal Guardian of the participant named above, I hereby give my permission for any adult DeMolay Advisor in attendance to secure, or any physician in attendance to provide, such emergency medical treatment as shall be deemed necessary by those present including, but not limited to, hospitalization, injections, anesthesia, surgery, x-ray, blood, and medications. I understand that every reasonable effort shall be made to contact me or the emergency contact prior to medical treatment.

I agree that if, in the opinion of any DeMolay Advisor that the participant be removed or asked to leave any DeMolay activity for violation of the Conference policies, that the undersigned will immediately take the necessary action to cause the transportation of the participant named above from the activity site at the expense of the undersigned Parent or Legal Guardian.

(If participant is under 18 years of age)

I have read, understand and accept the above statement