Columbus - PHYTH Collide 2025

Collide Retreat Registration

Nov 14th-16th | SkyView Ranch in Millersburg, OH | $150 per person
CONTACT INFO.
Student Name*

First NameLast Name
Which Campus Do You Attend?*
Parent/Legal Guardian Name*

First NameLast Name
Parent Email*
example@example.com
Parent Phone*
Please enter a valid phone number.
Student Phone
Please enter a valid phone number.

MEDICAL INFO.
Mediation Taken and Dosage for Each One
ANY type of medication for a student will be turned in before departure for SkyView Ranch, and distributed by a youth leader when necessary.
Allergies
Food Restrictions
Emergency Contact Info*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Relationship to Student*
Emergency Contact Info:
In the event that I cannot be reached in an emergency, I hereby permit the concerned church authorities to call 911 and/or to contact a medical facility or physician selected by the church to provide proper treatment to child's name stated in this form. I will be responsible for all expenses arising in association with such treatment.*

YES - I agree

RELEASE OF LIABILITY
Indemnity and Waiver of Claim:
I, the undersigned, parent/legal guardian of the child's name stated in this form, hereby agree to indemnify and hold harmless the church, its employees, volunteers, its governing board, the individual members thereof, and all other agents from any liability, lawsuit, cost, expense, or claim of any type whatsoever (including legal fees) for any harm, injury, or death arising out of the above mentioned activity, as a condition of the student participating in the same.
Parent/Legal Guardian Signature*

Clear
Date

MonthDayYear
Date
COLLIDE COVENANT AGREEMENT

1) I will represent the Potter’s House Church in a way that represents Christ that will be displayed through my speech and actions.

2) I will be respectul and considerate of all who are on the trip.

3) I will listen to and follow instructions of my Youth Pastors and leaders.

4) I will stick with the group and will not venture off.

5) I will align my conversation and language with the Word of God.

6) I will NOT bring any illegal substances, weapons of any kind, or act in any manner that could bring harm to myself or those around me.

I understand and have read the following. I promise to abide by all of the rules listed in this covenant agreement.
STUDENT Signature*

Clear
I understand that if my student breaks this covenant agreement can be sent home at my expense.
Parent/Legal Guardian Signature*

Clear
SkyView Release of Liability.

Please download this form and email it completed to fpease@potterhouse.org

https://drive.google.com/file/d/1ilVWRrWY-i2kaT5C8G41j5Uk8TLYQZs0/view?usp=share_link

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Collide Retreat Registration

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