Youth Retreat 2019

General Info

When: March 8-10th 2019.
Due Date: Register by February 20th, 2019.
Cost: $75 / $80 after 2.20.19 (Speak with P.Nick for scholarship info)
Where: Lake Geneva Christian Center Alexandria, MN

Participant Info

Student Name

Sex

Male Female

Birthdate

Grade

7 8 9 10 11 12

Address

Student Cell

This address will receive a confirmation email

Rules

Students are under the authority of New Life Church staff and volunteers. No stealing, illegal drugs, weapons, tobacco, fighting, sexual activity, or alcohol. On overnight events, no members of the opposite sex are allowed in a room or tent together without supervision. No wandering off alone. No cell phones during camp, missions trip, or any Wednesday night or Convention services. Students who damage property are responsible for repair/replacement. Parents may be asked to drive and pick up the student(s) if rules are violated.

Medical Info & Liability Release

I understand the nature of the New Life Church activities in which my son/daughter will be participating and that he/she is expected to abide by all church and facility rules during the course of the activities. I, acting on my own behalf, also release New Life Church, its staff, and volunteer leaders from any liability whatsoever arising out of disregard of rules, property damage, or loss as well as any injury, sickness, or death which may be sustained by my child as the result of participating in any New Life Church activity. I hereby give my permission for him/her to participate in the Youth Retreat on March 8-10th, 2019.

I authorize New Life Church to use our child’s likeness in photographs or video in any and all of its publications, website, and other media. I will make no monetary or other claims against the church for the use of such photos or videos. I understand that if my child misbehaves and violates the New Life Church rules, I may be called to pick him/her up from any activity.

I give my permission for the local physician to treat the listed student in the event of a minor illness or minor injury. In case of emergency, and when I am unable to be contacted, I hereby give permission to the local physician selected by New Life Church staff or volunteers to hospitalize, secure proper treatment for, order injection, anesthesia, or surgery for my child.

I understand and agree to the terms above

Yes

Insurance Coverage?

Yes No

Insurance Policy #

Phone #

Prescription Medicine

Health problems/Limitations

Allergies?

My child may be given pain reducing medication (tylenol, Aspirin, etc.) as deemed necessary?

Yes No

Parent/Guardian Information

Parent/Guardian(1)

Cell

Parent/Guardian(2)

Cell

Emergency Contact Name

Emergency Contact

This address will receive a confirmation email

Parent Signature

Signature Date

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

March 8-10, 2019

Youth Retreat 2019

Description

Please Fix the Following