SHIFT RETREAT September 15-17
Registration Forms must be submitted by August 27th, 2023, Send One church check $60/student (Check made out to East Tennessee NDI) Mail it to: Mount Juliet Church of the Nazarene attn. Theo Cox, 3290 N Mount Juliet Rd, Mount Juliet TN 37122 Phone: 615-450-3763 Email: Theo@mjnaz.org
I am registering as an:
Student/Participant
Junior Counselor
Adult Counselor
Student Name
First Name
Last Name
Student Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Phone Number
Please enter a valid phone number.
Student Email
example@example.com
Student Birthday:
-
Month
-
Day
Year
Date
Counselor Name:
First Name
Last Name
Counselor Email
example@example.com
Counselor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Counselor Phone Number
Please enter a valid phone number.
T-Shirt Size (Adult Sizes)
Please Select
Extra Small
Small
Medium
Large
X-Large
Emergency Contact:
Name
*
First Name
Last Name
Cell Phone Number
*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
By Signing below, you agree to get a district background check (adults) if needed and are at least 15 years of age or older (counselors). You also agree to follow any Nazarene Safe protocol to ensure that campers and staff are protected. Parent Signature is required for Junior Counselors.
*
Parent Signature for Junior Counselors:
*
Submit
Should be Empty: