Winter Retreat Registration

Health Care in case of emergency
Prescribed medications taken regularly:
Note food allergies:
Do you have Health Insurance Coverage? *

Yes No
Health Insurance Company
Policy Number
I do not have medical insurance and will not hold Child Evangelism Fellowship and/or any of their departments, partnerships, churches, officers, volunteers, agents, employees, and affiliates responsible for covering any expenses incurred due to accident, injury, or illness. Parent/Guardian Signature

Clear
I hereby certify that my child (listed above) is in good health, free from communicable disease and able to participate in all activities *

Yes No
Emergency Contact Information
Name *

First Name Last Name
Emergency phone where contact can be reached during this retreat *

Area Code Phone Number
Parent/Guardian e-mail address
example@example.com
Signature of Parent/Guardian *

Clear

Payment

Mail to: CEF of WI 2821 8th St S STE 5 Wisconsin Rapids, WI 54494 by Friday, January 29th or pay online.
Early bird ($100) special ends January 25th.

Starting Tuesday, January 26th the cost is $110.

No registrations will be accepted after midnight on Sunday, January 31st.

Payment needs to be sent to the state office CEF of WI by February 3rd.

Online payment option. There is an additional $3.00 processing fee for paying online. Once you submit this form, there will be a link to make an online payment.
Should be Empty:

Payment