top of page

Office - (903) 872-3664

Fall Retreat 2023
Student Registration

Take Me Back

Student Information

Student First Name

Student Gender

Student Last Name

Date of Birth

Address

Parent Information

Parent First Name

Mobile Number

Parent Last Name

Parent Email

Church Information

Which church do you attend?

Authorized Pick Up

Please enter up to two people authorized to pick up your student. If the parent/guardian listed above is one of them then their information must be entered below as well.

Authorized Pick-up #1

Authorized Pick-up #2

Driver's License/State ID

I understand only the persons listed above may pick up my student. NO EXCEPTIONS!

I understand that the ID listed above must be shown to pick up my student

Medical Information and Waiver

Emergency Contact

Insurance Provider

Insurance Policy No

Insurance Subscriber Name

Emergency Contact Phone

Insurance Phone No

Insurance Group No

Insurance Subscriber DOB

Allergies

List all food allergies

List all environmental allergies

List all medical allergies

Medications

List all medications

List all physical activities that your student cannot participate in

I understand all medications must be turned in to medical staff who will administer medications to my student

I give permission for medical staff to administer medication to my student as needed

Waivers and Releases

Camp Rules

Fall Retreat 2023 Paintball Release.pdf

Camp Waiver and Release Form

Photo Use Agreement .pdf

I have received the following documents and I agree to all terms....

Camp Rules

Camp Waiver and Release

Paintball Release

Photo Use and Release

Add your options to the cart

Registration

Concessions Tab

I understand that registration will not be refunded after October 31, 2023. NO EXCEPTIONS. This policy is not for paintball & concessions.

I agree to receive SMS text updates regarding retreat. Standard text rates may apply.

I understand that no refund will be given for shirts after shirt orders are placed

I understand my shirt must be prepaid to be ordered

Parent / Guardian Signature

bottom of page

Fall Retreat 2023 Student Registration