ReTribe Teen/Young Adult 2019 Registration Form
For Adventure Game, Inner Journeys, and Young Adult retreats
Full Name of Participant *
Your answer
What do you like to be called? *
Your answer
Participant Date of Birth *
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Participant Gender Identification
Your answer
Participant Email *
Your answer
Participant Cell Phone
Your answer
Mailing Address
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
School Attending?
Your answer
Where did you hear about us? (If it was the internet, we’d very much appreciate knowing what website it was and how you came upon it)
Your answer
Parent/Guardian Name (if under 18)
Your answer
Parent/Guardian Email
Your answer
Parent/Guardian Phone (home? cell?)
Your answer
Second Parent/Guardian Name
Your answer
Second Parent/Guardian Email
Your answer
Second Parent/Guardian Phone (home? cell?)
Your answer
Emergency Contact Name and Relationship *
Your answer
Emergency Contact Phone (home? cell?) *
Your answer
Health Insurance Name and Policy Number
Your answer
Do you have any dietary restrictions? *
Your answer
Do you have any special lodging needs?
Your answer
Please list any medical conditions (list medications if any).*Note on Medications: Even if your teen is responsible, we like to remind them to take their meds. In a new routine, and in the middle of wild fun, sometimes they might forget, and we recognize the importance of taking meds on time. Please list here the name of the medication, the dosage, and what time of day it should be taken, and whether it should be with meals, not with meals, or whether it doesn't matter.
Health History
Your answer
Please list any psychological conditions or situations that we should know about. (list medications if any).
Your answer
We provide optional video game addiction programming on our Adventure Game Theater retreat for those who would benefit. Would this interest you?
Are you in recovery from addiction to drugs or alcohol? If yes, for how many months/years?
Your answer
Do you currently smoke?
If yes, would you be willing to quit smoking during the retreat?
We have a zero-tolerance policy for the use of illegal drugs and alcohol during this retreat by anyone, including staff and teens.
We send an email list to everyone for ridesharing before the retreat. Please check below if you DO NOT want your information shared.
We would like to put your email on our email list to let you know information about this event and future retreats and gatherings. This list will not be sold. Please check below if you DO NOT want to be on our email list.
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