Youth Winter Retreat 2023

Camper's Name*

First NameLast Name

Gender*

GirlBoy

Age*

Birth Date*

Date

Grade as of this Fall*

Church Name*

Wellspring Family ChurchOther

Camper lives with:

Both ParentsMotherFatherOther

All Campers will receive a T-shirt. Please select size.*

If possible, please put in a cabin with:

List up to 2 friends within one year of age. We will try to match you with one of them

Do you want to register another camper?

Camper's Name*

First NameLast Name

Gender*

GirlBoy

Age*

Birth Date*

Date

Grade as of this Fall*

Church Name*

Wellspring Family ChurchOther

Camper lives with:

Both ParentsMotherFatherOther

All Campers will receive a T-shirt. Please select size.*

If possible, please put in a group with:

List up to 2 friends within one year of age. We will try to match you with one of them

Do you want to register another camper?

Camper's Name*

First NameLast Name

Gender*

GirlBoy

Age*

Birth Date*

Date

Grade as of this Fall*

Church Name*

WellspringOther

Camper lives with:

Both ParentsMotherFatherOther

All Campers will receive a T-shirt. Please select size.*

If possible, please put in a group with:

List up to 2 friends within one year of age. We will try to match you with one of them

Parent/Guardian #1*

First NameLast Name

Parent/Guardian #1*

Area CodePhone Number

Parent/Guardian Email #1*

example@example.com

Parent/Guardian #2

First NameLast Name

Parent/Guardian #2

Area CodePhone Number

Parent/Guardian Email #2

example@example.com

Parent Agreements and Authorizations

We recognize that campers must follow safety guidelines, remain in designated areas, and refrain from harmful behavior.
If a camper is unable to live within these guidelines, they may be sent home without a refund of camp fees.
Our child has permission to take part in all camp activities, under the Camp Staff’s supervision.
We agree to hold harmless Wellspring Family Church, St. Paul's Evangelical Free Church, other churches involved in hosting the event, Pinecrest Camp and Conference Center and their affiliates for all injuries or damages.

By entering my name here, I acknowledge my consent to all of the above Parental Agreements and Authorizations*

Please enter your name and today's date

By entering my name here, I consent that my child’s photo may be used for future ministry event promos and/or on the camp web site.*

Please enter your name and today's date

Other Information: To help camp leaders make a significant contribution to the Christian growth and development of this camper, please give any information about the camper that you feel would be helpful.

Please, also, tell us who is providing this information

Briefly describe any allergies, medical concerns, recent trauma, life changes or physical limitations the directors and staff should be aware of. (include additional details below)

Do any of your children have any food allergies? If yes, please list below.

Emergency contacts if unable to reach parents:

Emergency Contact #1*

First NameLast Name

Emergency Phone #1*

Area CodePhone Number

Emergency Contact Relationship #1*

Emergency Contact #2

First NameLast Name

Emergency Phone #2

Area CodePhone Number

Emergency Contact Relationship #2

UPLOAD COPIES OF INSURANCE CARDS

Browse Files

List any limitations on Camp Activities, or other medical conditions that the camp staff should be aware of:

Please include a list of all prescription medications, and directions, that will accompany each camper.

Note: all medications must be in original bottles with pharmacy information visible.

Does the camp medical staff have your permission to dispense over-the-counter medications (e.g., ibuprofen, cough drops, Benadryl, etc.)*

YesNo

The Health information provided on this form is correct as far as I know, and the above minor person has permission to engage in all prescribed camp activities except as noted. l hereby give permission to the medical personnel selected by the camp administration to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. ln the event that l cannot be reached in an emergency, l hereby give permission to the medical personnel selected by the camp administration to secure and administer treatment, including hospitalization, for the person named above.

By entering my name here, I acknowledge my consent to the above statement*

Please enter your name and today's date

Show me the packing list

HideShow

Winter Retreat Packing List

Camp is rough on clothes and gear. Items that are older and less expensive are recommended. We ask that campers wear closed-toed shoes at all times. This avoids cuts and slivers in the feet and to make walking, hiking and running more safe and enjoyable. Flip-flops are permissible in showers only.

Clothing should be appropriate for a church camp: modest in fit without inappropriate words or messages.
Camp policies prohibit campers from using or possessing tobacco products, alcoholic beverages, non-prescribed drugs or weapons at camp. Any camper using or possessing any of these items will be sent home immediately with no refund.
Leave cell phones, ipads, and other electronics at home.

CLOTHING: (in addition to what campers wear to camp)

Change of clothes for Saturday & Sunday (appropriate for the weather)
Warm clothes, coat, gloves & hat, shirts, jeans, undergarments, socks, tennis shoes, pajamas, etc (no spaghetti strap, halter, or crop tops permitted)
Dark clothing for outdoor night game
Swim suit (if desired for indoor pool)-no bikinis
Bible
Pen and notebook
Camera (if desired)
Flashlight and batteries
Sleeping bag or bed sheets & blanket
Dirty clothes bag
Pillow
Toiletries, towel and washcloth
Toothbrush, toothpaste, hairbrush, deodorant,
A good attitude
A readiness to grow in your relationship with God

DO NOT BRING:

Food containing nuts (we may have students with peanut allergies) That includes Reeses, Snickers, Baby Ruth, Butterfinger, you get the idea...)
Electronics / Digital devices (Cell phones, mp3 players, tablets, etc)
Energy drinks
Weapons of any kind
Illegal drugs
Fireworks
Expensive items or clothing
Excessive snacks
Zebras
Couches
Pandas
Light bulbs
Microscopes
Blimps
Space ships
Brussel sprouts
Catnip
Ceiling fans
Banks
Swamps
Sushi
Outlet covers
Airplane seat folding tray (unless it is in the upright and locked position)

Payment*

Pay later with check or cashPay online now with a credit cardRequest Financial assistance

Please mail or bring your payment to:

Wellspring Family Church

5293 South Lindbergh Blvd.

St Louis, MO 63126

Pay now with a credit card

Register (1) One Child$150.00

Payment for one camper

Register (2) Two Children$300.00

Payment for two campers

Register (3) Three Children$450.00

Payment for three campers

Enter coupon

Total $0.00

Credit Card

To request full or partial financial assistance with the registration fees, please contact Pastor Steve Otey directly by email at steve@wellspringfamily.org

All requests are confidential

President's Day Youth Retreat 2023

PARENT/GUARDIAN INFORMATION

Health Information

Credit Card