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One Weekend Retreat
January 12-14, 2018
Cost $30
Name of Student Attending *
Your answer
Student Contact Info. *
Your answer
Male/Female *
Grade of Student Attending *
T-Shirt Size *
Church Attending with *
Parent or Legal Guardian *
Your answer
Address *
Your answer
Phone *
Your answer
Email *
Your answer
Name of Emergency Contact if above parent/guardian cannot be reached *
Your answer
Emergency Contact Phone *
Your answer
Student Insurance Company *
Your answer
Insurance Policy Number *
Your answer
Does Student have any allergies *
If Yes list allergies below *
Your answer
Please list any other physical difficulties or conditions to which we should be alerted *
Your answer
Name of any regular medication *
Your answer
Current on immunizations for *
Required
In Case of Medical Emergency (Type parent name for e-signature) *
I hereby give permission for my child to attend and participate in the One Weekend Retreat. I understand that, in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give my permission to the sponsors in charge to secure medical treatment.
Your answer
I understand that the $30 payment is to be paid (cash, check, or money order) to the church which I signed up to attend. *
Date (of signature) *
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