Fall Retreat
Group Registration for Leaders

Take Me Back

Leader Information

Leader First Name

Address

Leader Last Name

Date of Birth

Mobile Number

Church Information

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

Waivers and Releases

I have received the following documents and I agree to all terms & conditions:

Camp Rules

Waiver and Release

Paintball Release

*paintball is an additional charge

Photo Use and Release

Optional add on's

I understand that my church will receive an invoice for the registration ($65) and for any additional add-on's

I understand that paintball will come with 3 canisters. Additonal canisters may be purchased at $5ea

Fall Retreat Group Registration for Leaders