ABC NE Youth Retreat 2018
Registration Form
Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone # *
Your answer
Your email address *
Your answer
Gender *
Roommate Request *
Your answer
T-shirt Size *
T-shirt is not guaranteed if you register after March 4th
Parent/Guardian *
Your answer
Parent/Guardian Address *
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone #
Best # to reach you in case of emergency. Please include cell #
Your answer
Additional contact person
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
How related
Your answer
Medical Insurance Company
Your answer
Group #
Your answer
Policy #
Your answer
Any health issues we should be aware of including dietary
Your answer
Medications currently taking
Your answer
Waiver Section- type your name below to give permission for your child to attend
I give permission for my child to participate in the normal activities associated with Camp Merrill, including hiking and zip line. Any exceptions are listed under camper restrictions. I realize that some of these activities may involve danger & risk of bodily injury. I hereby and voluntarily release, discharge, waive and relinquish any & all loss or damages or actions or causes of action for personal injury, property damage or wrongful death occurring to my child during his or her stay at Camp Merrill. • I give permission for the camp to administer medications as it deems necessary to my child. This includes medication sent with my child, or nonprescription medications available at camp. • In case of an emergency I understand every effort will be made to contact me. In the event I cannot be reached, I give my permission to the physician selected by the camp to hospitalize and secure proper treatment (including surgery) for my child. • I give permission for any photos taken during camp to be used for camp publicity. • If my child needs to be removed from camp for disciplinary or health issues I agree to pick them up promptly.
Your answer
Church you attend
Your answer
Pastor
Your answer
Payment options
Please check the payment options you will be using.
How much is your church paying of the registration fee?
Your answer
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