2019 Leadership Retreat Registration Form
The Mademoiselle Service & Social Club is hosting its Annual Leadership Retreat at Camp Lutherhill Ministries on July 19- July 21, 2019. Camp will feature leadership building, and effective communicating workshops. There will be Alumnae, Sponsors, and Parents in attendance as chaperones.

Please fill out this form in its entirety. All students will be notified via e-mail throughout the summer with camp updates. A MANDATORY Parent Meeting for ALL REGISTRANTS will be held in June 23, 2019.

ALL REGISTRANTS, including adults, must fill out the registration form.

Camp Information:
• Dates: Friday, July 19 – Sunday, July 21, 2019
• Location: Lutherhill Ministries
3782 Luther Hill Road
La Grange, TX 78945-4132
www.lutherhill.org
• Contacts: Brandii Mayes (832.605.3077)
• Parent Meeting: TBD

Member Registration Fees:
$40/person
Chapters must have 2 registrants

Non-Member Fees (non-Mademoiselles)
$65/person

Registration Deadline:
• Registration fees are must be paid via PayPal
• Registration forms must be submitted July 10, 2019
Name *
School
Chapter (Members Only)
Phone Number *
Email Address *
Sponsor Name (Members Only)
Sponsor Phone Number (Members Only)
Classification in the 19-20 Academic Year
Clear selection
Office in the 2019-20 Academic Year (Members Only)
Clear selection
Emergency Contact Name & Number *
Allergies/Physical & Dietary Restrictions/Current Prescription (provide Doctor's note for restrictions)
Special Instructions (not included above)
Waiver and Release by Parent for Minor *
The PARENT/GUARDIAN understands that the 2019 Leadership Retreat is an off-site (out of town) trip and gives permission for their daughter to participate in all phases of camp activities. The PARENT/GUARDIAN acknowledges that any activity involving physical activity involves a risk of injury. The PARENT/GUARDIAN understands and acknowledges that their daughter will be transported by other parents, sponsors or members of the Mademoiselle Service and Social Club in their vehicles. The Mademoiselle Service and Social Club will not be held liable for any injuries or damage to the undersigned's daughter, subject to any claim demand, injury or damages, whatever, including, without limitation, those damages resulting from the acts of active passive negligence on the part of the PARENT'S/GUARDIAN'S daughter. The PARENT/GUARDIAN represents that their daughter is able to undertake physical activity.
Photography Release *
Physical Activities Release: My Daughter MAY NOT participate in the following activities
I swear that the information provided is true to my knowledge. *
Student Name *
Parent Name (serves as Signature) *
Date Signed *
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