2020 HS Winter Retreat Registration
Friday, January 17 -- Sunday, January 19, 2020 at Dickson Valley Retreat Center, Newark, IL
Sign in to Google
to save your progress.
Name of Participant
Parent Email Address
Parent Phone Number
Emergency Contact and Phone Number
Medical Insurance Company & Policy Number (Please submit a copy [front & back] of your insurance card to St. John Lutheran Church via email to "
Please list allergies and medical conditions:
Please list any prescription medications your student may be taking:
Please check if it is permissible for us to administer the following medication for minor aches and pains:
Ibuprofen (Advil, Motrin)
Antacids (Tums, etc.)
How will you pay?
Cost for Winter Retreat is $125/person. Includes all meals, 2 nights of lodging, and activities. Make checks payable to "St. John Lutheran Church" Memo line: 2020 Winter Retreat. Please remit payment to Pam Kornaus in the church office.
Indicate your plan to pay:
$50 deposit due January 5; $75 due January 12
$62.50 deposit due January 5th; partial scholarship needed
I request a scholarship for the full amount
I request a different due dates for deposit and total payment
Expectations and Permission: Please Review
As a parent/guardian, I reviewed the information about the St. John High School Winter Retreat located at Dickson Valley Retreat Center (8250 Finnie Road, Newark, IL 60541) and give permission for my child to be involved in the overall activities from January 17 - 19, 2020. My child and I agree on the following expectations: An open door policy is set by St. John and volunteer staff; participants are expected to follow Dickson Valley Retreat Center and St. John rules. We agree that our participant will not leave early or come to retreat late unless arrangements are made in writing by email to Pastor Evan prior to the retreat. We agree participant will take transportation arranged by St. John, and no participant will be allowed to drive themselves to or from retreat. We agree participant will conduct themselves as part of St. John Lutheran Church. Any rude language, abusive treatment, or illegal drugs seen on participants by volunteer or St. John staff will result in participants being sent home early, at the inconvenience and cost of the parents of the participant.
The participant agrees to dress appropriately, and will bring all outdoor gear requested, even if they don't want to or feel it's unnecessary. Pastor Evan doesn't care what the participant thinks about outdoor gear. He knows you will thank him later. So bring it all. Seriously. Bring your outdoor gear. And deodorant. We will make every effort to ensure participant's safety, and participant agrees to follow all safety rules. As parents, we authorize any treatment by an accredited urgent care, hospital and/or physician deemed necessary for the subject of the release in case of an emergency; St. John staff and volunteers will make every effort to contact parents if medical treatment is needed. We understand the possibility of unforeseen hazards and know the inherent possibility of risk to participant. We agree not to hold St. John Lutheran Church of Joliet, IL, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the participant on the retreat.
Do you agree to the expectation and give permission for your child to attend Winter Retreat?
Yes, I agree, and I hereby consent to the above by this electronic signature.
Date of Signature
Name of Church:
Page 1 of 1
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service