Youth MINI RETREAT 2019

JUNE 28-29

Online Registration Agreement*
PLEASE READ THIS AGREEMENT CAREFULLY AS USE OF THE SERVICE CONSTITUTES ACCEPTANCE OF THESE TERMS AND CONDITIONS. IF YOU DO NOT AGREE, DO NOT REGISTER. Online registration for this event may only be completed by an adult eighteen years old or older. The registration of a child under thirteen years old must be completed by that child's parent or legal guardian.
- I agree
- I do not agree
Youth Name*
First Last
Child 1 Birthdate*
Date Format: MM slash DD slash YYYY
Child 1- Last grade completed*
Child's Name-2 (Only if have more than one child to register)
First Last
Child 2 Birthdate (if applicable)
Date Format: MM slash DD slash YYYY
Child 2- Last grade complete
Parent/Guardian Name*
Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Primary Phone*
Parent/Guardian Secondary Phone
Parent/Guardian Email
Allergies/Health information/Special Needs
Please provide us the appropriate information. Leave blank if not applicable.
Emergency Contact #1
First Last
Emergency Contact #1 Phone
Emergency Contact #2
First Last
Emergency Contact #2 Phone
May we photograph your child? Images may be used in end of program video/on our church website.*
- Yes
- No
If you are a member/regular attender at a different church, where at?