Fall Retreat
Group Registration for Leaders

Leader Information

Leader First Name

Address

Leader Last Name

Date of Birth

Mobile Number

Emergency Contact

Insurance Provider

Insurance Policy No

Insurance Subscriber Name

Emergency Contact Phone

Insurance Phone No

Insurance Group No

Insurance Subscriber DOB

List all food allergies

List all environmental allergies

List all medical allergies

List all medications

List all physical activities that your student cannot participate in

I understand all medications must be turned in to medical staff

Camp Rules

Waiver and Release

Paintball Release

Photo Use and Release

I understand that my church will receive an invoice for the registration ($75) and for any additional add-on's