Pinecrest Plus 2023 Registration Form

Pinecrest Plus 2023:

Johnsonburg Camp & Retreat Center, Blairstown NJ

October 20-22, 2023

Registration Deadline: October 4, 2023

Name

Date of Birth

Date

Mailing Address

Email Address

example@example.com

Do you have any special dietary restrictions or allergies? Please detail thoroughly to ensure proper accommodations

Please list any medical allergies, chronic medical conditions, or medication administration that needs staff support here

Emergency Contact Name

Emergency Contact Phone

Relation to Participant

*Please provide a copy of the participant's primary insurance card with registration*

Take Photo of Insurance Card

Upload Insurance Card Image

I hereby agree to allow Peter Teichmann or any appropriate Johnsonburg Camp & Retreat Center staff member to discuss my medical needs in the event of an emergency with medical personnel and my emergency contact.

Participant Signature

Date

By signing here I am acknowledging my personal responsibility to abide by the rules of both Pinecrest Lutheran Leadership Ministries event policies, as well as the rules of our host, Johnsonburg Camp & Retreat Center. I agree to respect my fellow attendees in a way that reflects Pinecrest's community of Christian faith, and respect my environment in a way that honors God's great creation. I understand that should it be agreed that I am acting in a way that does not respect the rules or my peers and environment I will be asked to leave and prayerfully consider attendance of future events.

Participant Signature

Date

Registration Cost (includes lodging and all meals):

$235 shared rooms and shared baths (2 nights/6 meals)

Registration Deadline: October 4, 2023

To Register By Mail: Make check out to PINECREST LLM and mail with registration form to Alumni Director Peter Teichmann, 6 Crossman Place, Huntington, NY 11743.

To Register Electronically, press green "Submit" button below and proceed to paying online via Tithely or through the link at www.pinecrestllm.org/registration/registration-pinecrestplus