The Pack Youth High School Retreat l Registration Form

When: July 28-30

Parents of Rising 9th Graders - 2023 Graduates, make plans for your students to have a fun weekend away with us at Navarre Beach, FL. This will be a life-changing weekend for your students as they get poured into by our The Pack Youth Staff and Board, go to the beach/swim, play volleyball/basketball, volunteer with local organizations, t-shirts, and more.

Location: Navarre Beach, FL

Students Name*

First NameLast Name

My student is a high school student

YesNo

Room Placement*

MaleFemale

Student T-shirt Size*

Age*

Students Birthday

Date

Ethnicity*

Has your student ever gone to a summer retreat*

Parent/Guardian Contact*

Area CodePhone Number

Parent/Guardian Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

School Spring 2023*

School Fall 2023*

Grade Fall 2023*

Students Age July 28*

Guardians Phone Number*

Area CodePhone Number

Student Phone Number if they have one

Area CodePhone Number

Your Profession?*

Email

example@example.com

Relationship to student*

Guardians Phone Number*

Area CodePhone Number

Your Profession?*

Email

example@example.com

Student is allergic to Amoxicillin?*

Student is allergic to Bactrim/Septra/Sulfa*

Student is allergic to Ibuprofen *

Student is allergic to Latex*

Student is allergic to Penicillin*

Student is allergic to Tylenol*

Student is allergic to another medication*

If Yes, list medicine here

Asthma *

Celiac Disease *

Hard of Hearing *

Diabetes *

Hypoglycemia *

Migraines *

Eczema*

Cardiac Issues*

Sickle Cell Anemia*

Seizure Disorder*

Bladder/Kidney *

Gets ill when exercising in heat *

Physical Disability*

If Yes, please explain

Hospitalization in the last year? *

If Yes, please explain

ADD/ADHD *

Sleep Walking *

Night Terrors*

Depression *

If Yes, please explain

Anxiety *

If Yes, please explain

Bi-Polar/Psycho - Social Disorder *

If Yes, please explain

Autism Spectrum Disorder*

If Yes, please explain

Medicine

	Medication	How often is it taken?	When is it taken	Any additional info?
MEDICATION

Medicine

	Medication	How often is it taken?	When is it taken	Any additional info?
MEDICATION

Name of insurance

Policy Number

Name of Doctor

Doctor Phone Number

RELEASE AND LIABILITY

In consideration of student's attendance by THE PACK YOUTH for participation at our High School Summer Retreat, July 28-30, 2023, we (I), being 18 years of age or older, do for ourselves (myself and for and on behalf of my child - participant) do hereby release, forever discharge, and agree to hold harmless THE PACK YOUTH and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child - participant that occurred while said child is participating in the above-described trip or activity. Furthermore, we (I) and on behalf of our (my) child-participant, hereby assume all risk of personal injury, sickness, death, damage, and expense due to participation in recreation and work activities. Furthermore, authorization and permission are hereby given to the said organization to furnish any necessary transportation, food, and lodging for this participant. The undersigned further hereby agrees to hold harmless and indemnify said organization, its Directors, employees, and agents for any liability sustained by such organization as a result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto.

Authorization for Treatment:

We (I) are the parent(s) / legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in said trip and hereby give our (my) permission to display participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, we (I) hereby assume all transportation costs.

I, the parent/guardian, hereby attest that I have carefully read this permission to participate, understand its contents, and agree to its terms and conditions.

I agree

Relationship #1*

Name #1*

First NameLast Name

Phone Number #1*

Area CodePhone Number

Relationship #2*

Name #2*

First NameLast Name

Phone Number #2*

Area CodePhone Number

Relationship #3

Name #3

First NameLast Name

Phone Number #3

Area CodePhone Number

How will you be paying?*

PayPalCashCheckCashapp

My Products

Save a spot Deposit for Retreat$50.00

the deposit of $50 must be paid by April 28th (non refundable) the other $150 must be paid by June 4th Paypal: thepackyth101@gmail.com Cahsapp: $thepackyouth

Deposit For Retreat$150.00

(may not be refundable)

Full Deposit For Retreat$200.00

(may not be refundable)

Total $0.00

Today's Date

Date

Parents (sign yourself 18+) Signature

Clear

HIGH SCHOOL SUMMER RETREAT 2023

Family/Guardian Information

Spouse

MEDICAL HISTORY

HEALTH HISTORY

MEDICATIONS

Medical Insurance

Emergency Contacts

Payment