Youth Fall Retreat Registration

Student Information

Name

Address

Phone

This address will receive a confirmation email

Date of Birth

May we contact your student through the means provided?

Yes No

Allergies

Medications/ Other medical Instructions

I understand that my child’s photograph and video may be taken during youth events. In signing this, I provide consent for my child’s video and picture to be in print or electronic media for promotional and informational purposes.

Yes No

Parent/Guardian Information

Parent/Guardian Name

Address (If different)

Parent/Guardian Phone

Parent/Guardian Email

This address will receive a confirmation email

Youth Participants are expected to:
Represent Christ in all their words and actions.
Remain with the group at all times.
Be respectful to all in attendance including adults.
Follow all rules and instructions as directed by the youth ministry team.
Violations may result in dismissal at parent/guardian expense.

Payment $80

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Please fill out this form and click submit.

Youth Fall Retreat Registration

Description

Please Fix the Following