NSC Youth Retreat Registration Form
October 27-29, 2017
For Jr. and Sr. High students (Grades 6-12)
At Red Rock Bible Camp

Retreat Brochure: http://nassaustreetchurch.com/wp-content/uploads/2017/05/Brochure.pdf

Student's Full Name
Your answer
Student's Address
Your answer
Student's Cell Phone Number
Your answer
Student's Home Phone Number
Your answer
Student's Email
Your answer
Gender
Birth Date
MM
/
DD
/
YYYY
Grade
6 Digit Medical Number
Your answer
9 Digit Medical Number
Your answer
Does the student have any emotional, behavioural, physical, dietary, allergic or other concerns?
If yes, please state clearly.
Your answer
If possible the student would like to share a room with?
Your answer
Parent(s) or Guardian(s) Full Name
Your answer
Parent(s) or Guardian(s) Address (if different from student's)
Your answer
Parent(s) or Guardian(s) Cell Phone Number
Your answer
Parent(s) or Guardian(s) Home Phone Number (if different from student's)
Your answer
Alternate Emergency Contact (Name, Phone Number, & Relation to Student)
Your answer
Parental/Guardian Permission (Please check the boxes to confirm you have read and understand the permissions):
Required
Student Guidelines (Please check the boxes to confirm that the student understands the guidelines)
Required
Payment
Cheques or cash can be submitted at youth events, at info central on Sundays, or to the church office during the week. Please make cheques payable to "Nassau Street Church".

Early bird rate is $128.45 if paid by October 17.
Regular rate is $140.00 and is due by October 24.

You can also make a donation to help offset the costs of our leaders or students who are unable to contribute the full amount. If you would like to do this, please indicate in the box below.

Additional Donation Amount (optional)
Your answer
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