Mom and Me 2020
Riverside Camp and Retreat Center
Email address *
Event Dates: April 17-19, 2020
Event Cost: $100 per person
Not to exceed $300 per family. Financial Aid available. Please contact kimi@flriverside.org for more info
Family Member #1 (First and Last name) *
Your answer
Family Member #1 Mailing Address *
Your answer
Family Member #1 Phone number *
Your answer
Family member #1 Age *
Family member #1 Gender *
Family Member #2 (First and Last name) *
Your answer
Family Member #2 Mailing Address *
Family Member #2 Phone number *
Family member #2 Age *
Family member #2 Gender *
Family Member #3 (First and Last name)
Your answer
Family Member #3 Mailing Address
Family Member #3 Phone Number
Family member #3 Age
Family member #3 Gender
Please list any additional family members and their ages that are participating in the Mom and Me Weekend
Your answer
Please list any roommate requests for Mom and Me. You and your child will be placed in rooms with one or two other moms and their children. (If none are requested we will place Moms and their children in rooms with similarly aged and same gender children.)
Your answer
Emergency Contact Name (A person not attending Mom and Me) *
Your answer
Emergency Contact Relation (Mother, Father, Friend) *
Your answer
Emergency Contact Phone Number *
Your answer
Church Home
Your answer
Please provide the names of family members with dietary restrictions. Please provide any important information regarding their dietary restriction.
Your answer
After completing this form, credit card payments can be taken over the phone, or checks can be sent to Riverside Camp and Retreat Center 7305 County Road 78 LaBelle, FL 33935
I understand that my registration is not complete until full payment is received. *
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