Schedule

2/19/11 (Sat) 9:00 AM Depart Palisades Church.  Please arrive at church between 8:30-9:00 AM        

2/21/11 (Mon) 2:30/3:00 PM Arrive Palisades Church

Location: The Warwick Center

62 Warwick Center Road, Warwick, NY 10990

(845) 986-1164

Registration Due Sunday, February 14 (FINAL DEADLINE)

Registration Fee: $110

Suggested donation of $10 for snacks.  If you would like to donate $10 for snacks, please write a check for $120.  We thank you in advance for your contribution!

Where to Register?

Bring registration form and fee to Room 104 each Sunday from 1:15-2:00 PM

What to Bring

-Bible

-Pens/pencils

-toiletries (toothbrush, etc.)

-towel

-sleeping bag

-shower slippers for use when showering

-flashlight (very important)

-winter accessories: gloves, scarves, hats

-thick jacket

-tennis shoes that you can run in

What You CAN’T BRING

-mp3 players or electronic devices.  Only cell phones are allowed and even this will be turned off for the duration of the retreat.  Parents, please contact your son/daughter by calling Pastor Rana at 213-500-3750 or Pastor Paul 201-638-2507

-snacks are not allowed in the cabins.  We will be charged $50 per cabin that has food.  Please donate $10 to the general snack fund instead.

Any questions?

Pastor Rana 213.500.3750
Pastor Paul 201.638.2507

Deacon Elaine Cooke 201.750.9353

Please turn in:

 REGISTRATION FORM

 REGISTRATION FEE $110

 OPTIONAL SNACK DONATION $10

Please turn in this portion and check made payable to “Palisades Church.”  Please include student name and grade in “MEMO” portion.

Student Information

Name: ____________________________

Grade: _____  Gender:   M    F

Address: ___________________________________________________

            City:  ____________________   State: ______  Zip Code: _____________

Phone: _________________________

e-mail: _________________________________

Health Questionnaire

Please state any physical handicap, allergies, medication or restrictions:

__________________________________________________________________

Is the student allergic to any medicines? (Please bring any necessary medication)

__________________________________________

In case of emergency, parent or guardian can be reached at:

Name:______________________________ Phone: (______)_________________

Any Other Comments: ____________________________________________________________

_____________________________________________________________

Parental Volunteer

If you would like to volunteer as a parent, please check here: ⬰

Parental Permission

As the parent or guardian of the student mentioned above, I hereby grant permission of attendance as well as authorize the staff to make any necessary decisions in case of emergency and will be responsible for any expenses.

Parent/Guardian Name: ____________________________________

Signature: _________________________________  Date:  _____________

Office Use Only:   Registration form received(date): __________________

                               Payment:   Check    Cash     Amount: $_____________    Check No. ________