The Winter Escape Permission Form
Our middle school group will be taking a weekend trip to Northern PA. While the Breakaway Retreat in the fall has 500+ students and tons of energy, this weekend will be a much smaller group in a more intimate space. Of course, the weekend will still include lots of fun and games, but most importantly we will create space for connecting with God.

DATE: March 3-5
EARLY BIRD RATE: $150 if by February 12
LATE BIRD RATE: $175 if after February 12

DROP OFF STUDENTS: 5:30 pm on Friday, March 3 at Storehouse Church (1090 Germantown Pike. Plymouth Meeting)
PICK UP STUDENTS: 4:00 pm on Sunday, March 5 at Storehouse Church (1090 Germantown Pike. Plymouth Meeting)

To pay online, go to

What to bring:
•sleeping bag
•bath towel
•snow gear
•active clothes

What not to bring:
•cell phone
•iPods, video games, tablets
•alcohol, tobacco, drugs
•weapons, including pocket knives
•bad attitudes and plagues

Student's Name
Your answer
If your child has been invited to this retreat by a friend, what is that friend's name?
Your answer
Your answer
Address (Box # and road)
Your answer
Your answer
Your answer
Parent's Primary Phone
Your answer
Parent's Email
Your answer
May we add your email to our "Ignite Weekly" email update?
Student's Cell Phone
Your answer
Insurance Provider
Your answer
Group Number
Your answer
Policy Number
Your answer
Please list any medical concerns.
Your answer
May we use pictures with your child in it for social media and materials for this event and others in the future?
In case of medical emergency or general care, I give consent for medical treatment above by authorized personnel. I certify that my child has my permission to attend the Winter Escape with Storehouse Church. I understand that Storehouse Church will do all they can to ensure a safe and fun activity, and should my child break the rules, I may be required to pick up my child early from the event.
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