Breakaway Retreat 2017
A crazy/fun/powerful/awesome fall retreat by the Chesapeake Bay just for middle school students -- October 6-8
Student Name *
Your answer
Student Grade *
Parent/Guardian Name(s) *
Your answer
Parent/Guardian Cell Number(s) *
Your answer
Parent/Guardian Email Address *
Your answer
Emergency Contact Name & Number for Breakaway weekend
(if different from parent/guardian information listed above)
Your answer
Cost *
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?
Parental Consent
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,
Your answer
Would you lend your vehicle to be a "church van" for the weekend? (Check all that apply.) *
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