ACC Pine Valley Retreat Family Application

Guardian/Parent Full Name - 1*

First NameLast Name

Gender - 1*

MaleFemale

Marital Status*

SingleMarried

Phone Number - 1*

Please enter a valid phone number.

Email - 1*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Age at the time of retreat - 1*

Years in the faith - 1

Home Church*

City

Day & Time of Arrival at Camp*

I am willing to volunteer in the following ways - 1:

Comments regarding volunteering - 1

Names of potential nominees

Registering spouse?*

YesNo

Guardian/Parent Full Name - 2

First NameLast Name

Gender - 2

MaleFemale

Phone Number - 2

Please enter a valid phone number.

Email Address - 2

example@example.com

Age at the time of retreat - 2

Years in the faith - 2

I am willing to volunteer in the following ways - 2:

Comments regarding volunteering - 2

Names of potential nominees - 2

How many children would you like to also register?*

Reminder: This is recommended for families with children under the age of 18.

First Child Name

First NameLast Name

First Child Gender

MaleFemale

First Child age at the time of retreat

First Child Lodging Request (2 names)

Second Child Name

First NameLast Name

Second Child Gender

MaleFemale

Second Child age at the time of retreat

Second Child Lodging Request (2 names)

Third Child Name

First NameLast Name

Third Child Gender

MaleFemale

Third Child age at the time of retreat

Third Child Lodging Request (2 names)

Fourth Child Name

First NameLast Name

Fourth Child Gender

MaleFemale

Fourth Child age at the time of retreat

Fourth Child Lodging Request (2 names)

Fifth Child Name

First NameLast Name

Fifth Child Gender

MaleFemale

Fifth Child age at the time of retreat

Fifth Child Lodging Request (2 names)

Sixth Child Name

First NameLast Name

Sixth Child Gender

MaleFemale

Sixth Child age at the time of retreat

Sixth Child Lodging Request (2 names)

Seventh Child Name

First NameLast Name

Seventh Child Gender

MaleFemale

Seventh Child age at the time of retreat

Seventh Child Lodging Request (2 names)

Eighth Child Name

First NameLast Name

Eighth Child Gender

MaleFemale

Eighth Child age at the time of retreat

Eighth Child Lodging Request (2 names)

Ninth Child Name

First NameLast Name

Ninth Child Gender

MaleFemale

Ninth Child age at the time of retreat

Ninth Child Lodging Request (2 names)

Tenth Child Name

First NameLast Name

Tenth Child Gender

MaleFemale

Tenth Child age at the time of retreat

Tenth Child Lodging Request (2 names)

Please note: All rates are per person and include a $20 non-refundable fee. Please use the quantity selector for family members who will be under the same package.

Alert: Motel rooms are SOLD OUT

Rates*

Motel - Full Time - ages 12+Full time with meals, linens included

$300.00 QuantityPostmark

Dorm - Full Time - ages 12+Full time with meals

$260.00 QuantityPostmark

Family Dorm - Full Time - age 12+ (min. 6 people)Full time with meals

$260.00 QuantityPostmark

Dorm - Part Time (1 night) - ages 12+3 meals

$190.00 QuantityPostmark

Dorm - Part Time (2 nights) - ages 12+6 meals

$220.00 QuantityPostmark

Base CampBase Camp is recommended for men only! Base Camp is located behind the playing field. This camp consists of six large tents on a wooden platform, each capable of holding five bunk beds with a max capacity of ten people per tent. The tents have no heating or electricity, but PVBCC will allow "camping type" heating units and lighting. There is a bathroom facility including sinks, toilet, and shower that has electrical power. There is also a Base Camp Fire Ring that can be used. There is dirt road access to the area with ample parking.

$220.00 QuantityPostmark

Ages 8-11 - Full TimeFull time with meals

$125.00 QuantityPostmark

Ages 4-7 - Full TimeFull time with meals

$100.00 QuantityPostmark

Ages 3 and under - Full TimeFull time with meals

$ Free QuantityPostmark

Day Registration - Part Time - Child (ages 3 and under)

$ Free QuantityPostmark

Day Registration - Part Time - ages 12+No meals

$40.00 QuantityPostmark

Day Registration - Part Time - ages 4-11Includes lunch OR dinner

$30.00 QuantityPostmark

Day Registration - Part Time - ages 12+Includes lunch OR dinner

$55.00 QuantityPostmark

Day Registration - Part Time - ages 4-11Includes lunch AND dinner

$45.00 QuantityPostmark

Day Registration - Part Time - ages 12+Includes lunch AND dinner

$75.00 QuantityPostmark

Full Registration - Off-site LodgingALL meals

$150.00 QuantityPostmark

Linens (per bed)

$30.00 QuantityPostmark

Donationas unto the Lord

$5.00

Amount	Quantity	Price
$5		$5.00
$15		$15.00
$25		$25.00
$50		$50.00
$100		$100.00
$150		$150.00
$200		$200.00

Item subtotal:$0.00

Total

$0.00

Family Member Details*

Please list the names of each family member and which package/items they are receiving.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

ACC Pine Valley Retreat Family Application

Important Form Disclaimer

Nominees for PV Committee

Nominees for PV Committee