West Penn Winter Retreat 2019
For students attending the retreat at Camp Mantowagan January 11th-13th. Please turn all money in to your local youth group (if applicable) prior to the weekend of the retreat.
Please Note: This year's retreat is open to 7th-12th graders.
Emergency Contact Info
Parent (Guardian) name
Parent's Primary Phone #
Parent's Secondary Phone #
Please choose the youth group the student will be attending with.
Avis (Grace Fellowship Church)
Faith Bible Church (Bellwood)
Juniata (Grace Fellowship)
Leamersville (Grace Fellowship)
Nanty Glo (FBC)
Target One Ministries
Secondary Emergency Contact Person
Secondary Emergency Contact Phone #
Name of Health Insurance Provider:
Any allergies, medications, or special instructions:
If none, please type "N/A"
As parent (or guardian) I understand that the leaders of the West District Youth will supervise the students for the duration of the retreat. In an emergency, I hereby give permission to the licensed physician selected by one of the leaders of the West Penn District Youth to hospitalize and secure proper treatment (including surgery) for my student named above. Every effort will be made to contact you immediately should the need arise.
We will use this email address to confirm your registration as well as send any updates.
Type your initials as your electronic signature
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