116 Youth Retreat Permission Form

Name of Participant

First

Last

Gender

Male
Female

Date of Birth

Last Completed Grade

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Participant Phone#

Emergency Conact Name

First

Last

Emergency Contact Phone #

Please List all Allergies – Food/Medication etc…

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

Approved Medication

List all medications the participant will be bringing to the retreat. Also, What over-the-counter medications ( if any ) may your child take in the event of a fever, headache, cramps, body-aches, etc….

Name of Person Completing this Form

First

Last

Signature of Parent or Guardian Completing this form

Clear Signature

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.

Deposit for Attendance

Price: $25.00

You will be redirected to paypal where you can submit a $25.00 non-refundable deposit for attendance