Fall Retreat 2018
This form does NOT register you for Festival of Life at Eastern Nazarene College
Email address *
Student Name *
Your answer
2nd Student Name (sibling)
Your answer
3rd Student Name (sibling)
Your answer
Student Date of Birth *
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DD
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YYYY
2nd Student Date of Birth
MM
/
DD
/
YYYY
3rd Student Date of Birth
MM
/
DD
/
YYYY
Student's Grades 2018-2019 school year *
Required
Student's Address *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone number *
Your answer
Parent email address
Your answer
Emergency contact name & number other than parent/guardian *
Your answer
Student allergies and/or medical diagnosis we should be aware of. (Please use names if registering more than 1 student.) *
Your answer
Health Insurance information *
Your answer
Does your student have an I.E.P.? If yes, please include a few strategies that will help us help your child succeed while at retreat. (Please use names if registering more than 1 student.)
Your answer
Medications to be taken while at retreat: (Please use names if registering more than 1 student.) *
Your answer
My student(s) will (probably) be trying out for F.O.L. in the following areas: *
Required
Would you like to be added to an email list and receive District NYI promo materials and registration forms directly? *
Who is allowed to dismiss your student(s) from Fall Retreat? (Who can take him/her home?) *
Your answer
Do we have permission to post your student's likeness (photo or video) online such as, but not limited to: Facebook, Twitter, & Instagram? *
Do we have permission to transport your student(s) among locations while at Fall Retreat? (If no, a parent will need to at attend at his/her own cost in order to provide transportation.) *
Do you agree to send your student(s) at his or her own risk and not hold the Church of the Nazarene, its volunteers or employees liable for any harm that may occur while attending Fall Retreat? *
Is there anything else you'd like us to know?
Your answer
A copy of your responses will be emailed to the address you provided.
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