116 Youth Retreat Permission Form

Name of Youth Participant *

First

Last

Date of Birth *

Last Completed Grade *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Guardian Email

Youth Participant Phone#

Emergency Conact Name *

First

Last

Emergency Contact Phone # *

Please List all Allergies – Food/Medication etc… *

Is there any pertinent medical information that we should be aware of and/or reasons why this person may not fully participate in all retreat activities

Known Medical Conditions / Limitations *

Is there any pertinent medical information that we should be aware of and/or reasons why this person may not fully participate in all retreat activities

Terms and Conditions *

I have read, and I understand and agree to all terms and conditions stated below

Parental Permission : I hereby give my permission for my child ( Listed above on this form ) to participate in all activities of the 116 Youth Retreat. I agree to assume all risk of injury, harm, or damage to my child’s person or property. By signing this form, I give my full permission to seek emergency treatment of my child under the age of 18. I agree to indemnify and hold harmless all staff and participants from all liabilities, legal actions, damages, and claims of any kind or nature that may arise as a result of my child’s attendance at this retreat. By signing this permission slip, I understand the use of illegal drugs, beverage alcohol, the use of tobacco in any form, and/or weapons of any kind are strictly prohibited anywhere on the grounds or in any buildings/ vehicles. Any confiscation of and/or discovered use of the above mentioned items can result in the suspension of my child’s attendance at camp, I assume responsibility for any additional transportation arrangements or costs incurred as a result of this actions.

Guardian Signature *

Deposit

Price: $ 20.00

A $20.00 non-refundable deposit is required for attendance

How would you like to pay for the deposit? *

I’ll send my child with cash
Credit Card

Stripe Credit Card *

Card

Name on Card