Retreat Registration 2020

St. Paul Ev. Lutheran Church Youth Retreat Registration
Congregation*
Pastor
Pastor email
example@example.com
Pastor Phone Number

Area CodePhone Number
Male Chaperone (if different from Pastor
Male Chaperone email
example@example.com
Male Chaperone Phone Number

Area CodePhone Number
Female Chaperone
Female Chaperone email
example@example.com
Female Chaperone Phone Number

Area CodePhone Number
Additional Chaperone

First NameLast Name
Additional Chaperone

First NameLast Name
Additional Chaperone

First NameLast Name
Additional Chaperone

First NameLast Name
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Student name
First, Last
Birth Date

MonthDayYear
Phone Number (in case of emergency, from those listed above)

Area CodePhone Number
Health and Liability
Health needs (please list any health needs of which you would like us to be aware)
Informed Consent and Acknowledgement

I hereby give my approval for my group’s participation in any and all activities prepared by St. Paul Evangelical Lutheran Church during the youth retreat. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless St. Paul Evangelical Lutheran Church and all its respective officers, agents, and representatives from any and all liability for injuries to said family arising out of traveling to, participating in, or returning from Youth Retreat sessions.

In case of injury to said family, I hereby waive all claims against St. Paul Evangelical Lutheran Church including all teachers and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all activities.

During the Retreat, we take photographs of activities. These photos may be published on our website, social media pages, newsletters, etc.

Confirmation

BY ACKNOWLEDGING AND PRESSING SUBMIT BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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St. Paul Ev. Lutheran Church Youth Retreat Registration