Winter Wipeout Signup

Winter Wipe Out Sign Up (Jan 20-22).

Rock Hill Youth Winter Retreat at Camp Shamineau *Sign Up's due January 11th. This event is for both Middle and High School. We will leave around 4pm on January 20th.
Student Information
Student Name*

First Name Last Name
Additional Students

If you have more than one student coming to Winter Wipe Out, list their names below and this sign up will cover all of them.
Additional Student

First Name Last Name
Additional Student

First Name Last Name
Additional Student

First Name Last Name
Additional Student

First Name Last Name
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First Name Last Name
Additional Parent / Guardian Name:

First Name Last Name
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number*

Area Code Phone Number
E-mail*
Emergency Contact*

First Name Last Name
Emergency Contact Phone Number*

Area Code Phone Number
PAYMENT

The cost for the weekend is $115 per student. PAYMENT IS DUE JANUARY 20TH.
Will you be paying with..*

Online (Push Pay)Check
*If you'd like to pay online, follow this link: https://pushpay.com/g/rockhillcc?src=hpp&r=monthly

Click "give one time" and then from the dropdown menu select "Winter Wipeout"
Winter Wipeout Forms

Once you have signed up your student for Winter Wipeout, we will send you the form that will be required in order to go to the Retreat.
Should be Empty:

Winter Wipe Out Sign Up (Jan 20-22).