Youth Registration Form - Fall Retreat 2023

Join us on our Annual Youth Fall Retreat, held at Spring Lake Park Reserve in Rosemount on Sept 29, 30 and Oct. 1st. Cost is $30

Student Name * First Last
Date of Birth * / MM / DD YYYY
Gender *
Grade *
Parents/Guardians' Name * First Last
Home Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Parents' Cell * - (###) - ### ####
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Insurance Carrier
Policy/ID#
*
Insurance Company Phone * - (###) - ### ####
In Case of Emergency Contact: * First Last
Emergency Contact Phone * - (###) - ### ####
List of all current medication/dosage: *
Any activities to be restricted: *
HEALTH HISTORY: Does student have allergies, heart problems, asthma, blood disorders, past serious injuries, seizures, diabetes, past surgeries, chronic recurring illness, etc.? EXPLAIN. *
EMERGENCY AUTHORIZATION: * By checking this box give my child permission to attend Family of Christ's Fall Youth Retreat, Sept 29, 30 and Oct. 1st. In the event that I cannnot be reached in an emergency, I hereby give permission for the leadership of my church personnel to have an authorized doctor or medical professional, hospitalize, administer medical aid and treatments, order injections, anasthesia or sergery for my child at any time they believe an emergency exists. I will be responsible for all medical bills. I agree not to hold Family of Christ, Camp Spring Lake or the leaders responsible for any accident should it occur.
* My youth will be participating fully in the entire retreat, including driving up and returning with the group to and from church. My youth has conflict/schedule adjustments and can only participate in part of the weekend, and we will plan the transportation.
I can help donate food for meals and will look for the sign-up genius. Yes No Maybe
I can help chaperone for part of the weekend. No Maybe Yes Friday Night Saturday Day Saturday Night

Youth Registration Form - Fall Retreat 2023

Youth Registration Form - Fall Retreat 2023

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