Fall Retreat 2019 Registration Form
October 4-6, 2019 at Camp Wapsie in Coggon, IA (4:30 pm Friday - 1:30 pm Sunday)
Deadline to register and pay $35 to Christine is Thursday, September 26, 2019
Before you leave for the retreat you will be asked to sign a Waiver and Release from Liability Form
Transportation provided
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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