NewStory Youth | "ONE" Winter Retreat | Registration Form
INSTRUCTIONS:
-Please submit one form per student.
-Payment will be accepted in-person via check, made out to NewStory Church with students' name in memo.

DATES:
Friday, January 17, 2020 - Monday, January 20, 2020

LOCATION:
Pinecrest Christian Conference Center
1140 Pine Crest Rd., Twin Peaks, CA 92391
909-338-4243

COST:
$185 per child

*Sibling discount available! $10 off for 2nd child, $15 off for 3rd
*If finances are a challenge, please speak to Pastor Peter or ministry leaders privately so that your child can attend our retreat.

MINISTRY LEADERS:
-Peter Koo (Youth Pastor)
peter@newstorychurch.com | 714-873-5660
-Sam Whang
samwhang@yahoo.com
-Moshi Whang
moshiwhang@gmail.com
-Timoteo Lee
ynbrazil@gmail.com
Email address *
STUDENT INFORMATION
Student’s Last Name *
Your answer
Student’s First Name *
Your answer
Student’s Middle Initial
Your answer
Name of sibling(s) also attending New Story Youth Winter Retreat
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Grade
Sweatshirt Size (Adult sizing) *
PARENT INFORMATION
Parent/Guardian First and Last Name *
Your answer
Parent/Guardian Contact Phone Number *
Your answer
Parent/Guardian Email *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
STUDENT HEALTH INFORMATION
Allergies and/or Dietary Restrictions:
Your answer
Any other medical or health conditions we should be aware of?
Your answer
Health Insurance Company *
Your answer
Policy Holder Name *
Your answer
Health Insurance Policy Number
Your answer
Physician Name and Phone Number *
Your answer
Any Questions, Comments, Concerns?
Your answer
Check all that apply: *
Required
I have read the above and agree to its terms and conditions. Furthermore, should it be necessary for my child to return home due to medical, disciplinary, or other reasons, I hereby assume all transportation costs. *
A copy of your responses will be emailed to the address you provided.
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