Fall Retreat 2024 Youth Registration

Join us on our Annual Youth Fall Retreat, held at Spring Lake Park Reserve in Rosemount on Oct. 4, 5, and 6th. Cost is $30.00 per person.

Student Name * First Last
Birthdate * / MM / DD YYYY
Gender *
Grade *
Parent / Guardian Name * First Last
Home Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Parent Cell Phone * - (###) - ### ####
Insurance Carrier
Policy and ID#'s *
Insurance Company Phone Number * - (###) - ### ####
Emergency Contact Person * First Last
Emergency Contact Phone * - (###) - ### ####
List of all current medications/dosage *
Any activities restricted? *
Health History: Does student have allergies, heart problems, asthma, blood disorders, past serious injuries, diabetes, past surgeries, chronic recurring illness, etc.? EXPLAIN *
EMERGENCY AUTHORIZATION * By checking this box give my permission to attend Family of Christ's Fall Youth Retreat, Oct. 4, 5, and 6th. In the event that I cannot 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 surgery 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 Park or the leaders responsible for any accident, should one occur.
I can help chaperone for part of the weekend. * Yes No Maybe Friday Night Saturday Day Saturday Night
ATTENDANCE * My youth will be participating in the entire retreat. (ride in the church van) My youth will be participating in the entire retreat. (but will provide own rides) My youth has a conflict but will come when they can. (will provide own rides)