Youth Registration Form - Fall Retreat 2022

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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 * - (###) - ### ####
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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. *
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EMERGENCY AUTHORIZATION: * By checking this box give my child permission to attend Family of Christ's Fall Youth Retreat, October 28th-29th. 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.
* Student 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

Youth Registration Form - Fall Retreat 2022

Youth Registration Form - Fall Retreat 2022

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