Fall Retreat
Group Registration for Students

Take Me Back

This form is to be filled out by the group representative only!

Student Information

Student First Name

Student Last Name

Date of Birth

Address

Group Leader Information

First Name

Mobile

Last Name

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 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

Paintball Release.pdf

Waiver and Release

Photo Use Agreement .pdf

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

Camp Rules

Waiver and Release

Paintball Release

*paintball is an additional charge

Photo Use and Release

Select add-ons for this student

These items will be included on the invoice to the church

Concession tab amount

By signing below you certify that you have been appointed by the Pastor as the group representative for this church.

Group Leader Signature

Fall Retreat Group Registration for Students