Breakaway Retreat 2017
A crazy/fun/powerful/awesome fall retreat by the Chesapeake Bay just for middle school students -- October 6-8
Parent/Guardian Cell Number(s)
Parent/Guardian Email Address
Emergency Contact Name & Number for Breakaway weekend
(if different from parent/guardian information listed above)
The cost for Breakaway is $90 (checks to St. Paul's UMC, please!), and payment is due on the day of the retreat. If the cost would be prohibitive for your family, please talk to Dave and it will be worked out. No one needs to miss Breakaway because the cost is too high. Fair enough?
I give my permission for my child to attend and participate in Breakaway Retreat 2017. I hereby release St. Paul’s UMC, its staff and volunteer leaders, from responsibility and liability for any injury or illness that my child may sustain during this event. I authorize an adult leader, as an agent for me, to consent to an x-ray examination; medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under laws of the state where services are rendered, either at a doctor’s office, any hospital, or any clinic. I expect to be contacted as soon as possible. Signed,
Would you lend your vehicle to be a "church van" for the weekend? (Check all that apply.)
Our family can lend! Our vehicle has 6 seats, including the driver's.
Our family can lend! Our vehicle has 7 seats, including the driver's.
Our family can lend! Our monster vehicle has 8 seats, including the driver's.
Our family can lend as checked above, but we will need a substitute vehicle for the weekend.
Our family would consider lending, but we need more information.
Our family is unable to lend a church van-suitable vehicle for Breakaway weekend.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service