HS Retreat Student Registration Form
Friday, January 11- Sunday, January 13, 2019
Registration Dates
Registration Opens: November 11, 2018

Registration Closes: January 6, 2019

Registration Payment Dates:
EARLY BIRD REGISTRATION** (November 11- December 9): $99
REGULAR REGISTRATION (December 10 -January 6th): $110

**Deposit of $40 MUST be made by December 9th in order to receive Early Bird Pricing

Payment (cash or check) also accepted on Sunday mornings at the Next Gen Center in the Foyer
Student's Information
First Name *
Your answer
Last Name *
Your answer
Current Grade *
Gender *
Student's Cell Phone during Retreat (if applicable)
Your answer
Age *
Your answer
T-shirt Size *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
What BPF campus do you attend? *
Small Group Leader's Name
Your answer
Name TWO friends your student would like to room with during retreat *
Your answer
Parent/Guardian Information
Parent/Guardian Name(s) *
Your answer
Parent's Current Email (important retreat information will be sent to this email) *
Your answer
Parent's Email #2
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent's Cell Phone # *
Your answer
Parent's Cell Phone #2
Your answer
Emergency Contact Information
Emergency Contact's Name *
Your answer
Relationship to Student *
Your answer
Cell Phone Number *
Your answer
Student's Medical Profile
Family Physician's Name *
Your answer
Family Physician's Number *
Your answer
Does your student have Health Insurance? *
Name of Insurance Policy
Your answer
Insured Name
Your answer
Policy Number
Your answer
ID Number
Your answer
Insurance Phone Number
Your answer
Place of Employment
Your answer
Generally, my child's health is: *
If fair or poor, please explain your student's condition:
Your answer
Does your student plan to bring any medications to retreat with them? *
If yes, please list medications: (they will have to be checked in at the retreat registration)
Your answer
May your student have the following at medicine: (please check the ones that are approved) *
Required
Previous/Recent Serious Injury or Surgery? Chronic Medical Condition? *
If YES to any of the above, please describe:
Your answer
Date of Last Tetanus Shot *
Your answer
Allergies? (Food, Drugs, Insect Stings/Bites, etc) *
Your answer
Student Waiver Form
NOTE: To be completed and signed by parents or legal guardian of participants under 18 years of age.
I,_______________, Parent or legal guardian of a student attending BPF HS Retreat, hereby acknowledge that said minor is presently under my care, custody and control. I hereby give this minor my permission to go to High School Retreat, January 11-13, 2019. I further grant my permission for this child to participate in all activities of said camp. I have listed any physical limitations or medical problems that may need attention. In the event there arises an emergency, necessitating medical attention, I hereby consent and give my permission to Brazos Pointe Fellowship representatives, camp sponsors, or any attending physician/nurse to make such decisions and to perform such medical treatment and/or surgery upon said minor, which may in their sole discretion be necessary and proper under the circumstances. I understand that every effort will be made to contact me in the event of such an emergency. I do release, acquit, discharge and covenant to hold harmless the encampment, and its personnel, all representatives of Brazos Pointe Fellowship (Brazoria Road and Mid County Campus , from any and all actions, damages, liabilities arising out of the treatment of any sickness or accident incurred by said child during the retreat dates. I also give authority and permission to camp sponsors to inspect my student’s room and belongings while on camp grounds for the safety and protection of all participants if circumstances make it necessary. I understand that my child/student will be dismissed from retreat and sent home at my expense if he or she does not adhere to retreat rules. Parent and/or Guardian (or student 18 years of age or over in agreement with above waiver). *
Your answer
Photo/Video/Movie Release
NOTE: To be completed by parents or legal guardian of participants under 18 years of age.
I, ________________, parent of my student attending BPF HS Retreat, a minor, hereby give permission to Brazos Pointe Fellowship to photograph my student and use such photographs in all forms of BPF media, for any and all promotional purposes including publicity, display and audiovisual use.I understand that the term “photograph” as used herein encompasses both still photographs and audio and video recording footage. *
Your answer
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