Mom and Me 2020
Riverside Camp and Retreat Center
Email *
Event Dates: September 25-27, 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) *
Family Member #1 Mailing Address *
Family Member #1 Phone number *
Family member #1 Age *
Family member #1 Gender *
Family Member #2 (First and Last name) *
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)
Family Member #3 Mailing Address
Clear selection
Family Member #3 Phone Number
Clear selection
Family member #3 Age
Clear selection
Family member #3 Gender
Clear selection
Please list any additional family members and their ages that are participating in the Mom and Me Weekend
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.)
Emergency Contact Name (A person not attending Mom and Me) *
Emergency Contact Relation (Mother, Father, Friend) *
Emergency Contact Phone Number *
Church Home
Please provide the names of family members with dietary restrictions. Please provide any important information regarding their dietary restriction.
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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