Senior High Retreat
Please fill out this form and click submit.
Student's Name
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Student's Age
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Completed Grade
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If coming with a friend, give their name:
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Medical Insurance provider
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Policy/Group #
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Additional Medical Information (allergies, special needs, etc.)
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Parent's Name
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Parent's Email
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This address will receive a confirmation email
Parent's Phone Number
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Emergency Phone Number
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Address
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Parents/Guardians - Please read the Retreat Release and permission forms carefully below and "sign" by typing your name in the spaces provided. Thank you.
Retreat Release Form - The undersigned participant, and participant’s guardian if participant is under eighteen (18) years of age on the date hereinafter indicated, does hereby release and discharge Westminster Presbyterian Church, its agents, youth leaders, employees, volunteers, and representatives, from any and all liability in connection with any activities carried on during its 2018 SH Summer Retreat, June 13-14, including but not limited to claims of negligence, recklessness and any and all other claims alleging a failure to use reasonable care, including but not limited to claims made in connection with the use of transportation vehicles, facilities, buildings, land, fixtures, lake, kayaks and various field games and any other activities of any nature whatsoever conducted during its 2018 SH Summer Retreat. The undersigned hereby acknowledge that they have assumed all risk, known or unknown, in connection with transportation to and from and participation in the 2018 SH Summer Retreat. The undersigned parent/guardian further acknowledges that his/her son or daughter may be photographed or captured on video as a participant on the 2018 SH Summer Retreat, and grants full permission to Westminster Presbyterian Church to use photographs or videos in print, electronic, or public form.
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Permission Form - If participant is under eighteen (18) years of age, the undersigned parent/guardian, hereby authorizes his/her son or daughter to attend the 2018 SH Summer Retreat at New Beginnings Loft on June 13-14. In the event of an emergency, said parent or guardian understands that all will be done to contact him/her. However, if the parent/guardian cannot be reached, permission is granted to the physician selected by the youth leader to hospitalize and/or secure proper treatment for, and to order such injections, anesthesia, or surgery as may be deemed necessary for the child’s welfare and protection.
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Payment
$35
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
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AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
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