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.
Grade *
Please Note: This year's retreat is open to 7th-12th graders.
Participant's Name *
Your answer
Gender *
Emergency Contact Info
Parent (Guardian) name *
Your answer
Parent's Primary Phone # *
Your answer
Parent's Secondary Phone #
Your answer
Youth Group *
Please choose the youth group the student will be attending with.
Secondary Emergency Contact Person *
Your answer
Secondary Emergency Contact Phone # *
Your answer
Insurance Information
Name of Health Insurance Provider: *
Your answer
Policy Number *
Your answer
Any allergies, medications, or special instructions: *
If none, please type "N/A"
Your answer
Consent
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.
Email Address *
We will use this email address to confirm your registration as well as send any updates.
Your answer
Type your initials as your electronic signature *
Your answer
*
MM
/
DD
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service