Gone Fishin' Fall Retreat 2018 Registration Form
October 12-14, 2018 at Camp Io-Dis-E-Ca in Solon, IA (4:30 pm Friday - 1 pm Sunday)
Deadline to register and pay $30 to Christine is Tuesday, October 9, 2018
Before you leave for the retreat you will be asked to sign a Waiver and Release from Liability Form
First Name *
Your answer
Last Name *
Your answer
E-mail address *
Your answer
Cell phone number *
Your answer
Local Address *
Your answer
Year in School *
Major *
Your answer
Date of Birth *
Your answer
T-shirt size *
Do you have any food allergies or dietary restrictions? Please explain. *
Your answer
Please list prescription medications you are currently taking.
Your answer
Do you have any other allergies or special needs that we should know about to make sure you are accommodated? Please explain. *
Your answer
Health Insurance Provider *
Your answer
Health Insurance Plan Number *
Your answer
In the event of an emergency please contact: *
Your answer
Emergency contact's phone number *
Your answer
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