2025 Winter Retreat Adults

Winter Retreat!
LEADER INFORMATION
Name*

First NameLast Name
Name Goes By
Birthday*

MonthDayYear
Date
Email*

Confirmation Emailexample@example.com
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-Shirt Size (Adult Sizes Only Please)*
Are you or will you registering additional family members?*

YesNo

MEDICAL INFORMATION
Medications on Hand: The over the counter medications listed below will be available if needed on occasion during the FUMCA Programming. Please check the medications below that you authorize the staff to administer to your student without contacting a parent for permission.*

Ibuprofen (Advil) 200 mgAcetaminophen (Tylenol) 500 mgPepto-Bismol Tablets 262 mgBenadryl 25mg
MEDICATIONS: Will you (or your student) need to take any additional medications, prescription or over-the-counter, while at the retreat.*

YesNo
No problem! All medications, prescription and over-the-counter, must be turned in at the Medication Drop Off table at check-in. Medications should be sent in original containers if possible.
IMMUNIZATIONS: Date of participant's last Tetanus? Type "Unknown" if not sure. Please obtain a Tetanus if you are not current.*
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Insurance Provider*
Policy Holder's Name*

First NameLast Name
Policyholder's Date of Birth*

MonthDayYear
Date
Member ID number*
Group Number*
insurance Provider Phone Number, If Known
Please enter a valid phone number.Format: (000) 000-0000.
Medication and/or Food Allergies (N/A if none)*
CONSENT FOR TREATMENT: I hearby give permission to the physician selected by the FUMCA staff/adult volunteers to hospitalize, secure proper treatment for, and/or to order injection, anesthesia, or surgery for myself.
Signature of Participant (if participant is 18 or over on this date) or Parent/Guardian (if participant is under 18 on this date)*
Today's Date*

MonthDayYear
Date
PAYMENT OPTIONS
PAYMENT POLICY: Please note that all trip spots have been prepaid months in advance. As such:

*A non-refundable deposit is required at the time of registration.

*Refunds for any additional payments made will be issued so long as a cancellation is received via email to Trey Lemmon, trey@alabasterfumc.org, two (2) or more weeks prior to event start date.

*In the event of a no-show or a cancellation is received less than two (2) weeks prior to event start date, registered students/families will be responsible for the balance in full.

*Trip balances should be paid in full two (2) weeks prior to event start date.

*If an alternate payment plan is needed, please don't hesitate to reach out to Trey Lemmon, trey@alabasterfumc.org. Full or partial scholarships are available to any student in need.
We appreciate your understanding as this ensures we can keep registration fees to a minimum.*

We understand the payment policy outlined above and agree to it.
How Would You Like To Pay?*

I would like to pay in FullI would like to receive a Scholarship

My Products

Pay in Full

$200.00

Half Scholarship

Whole cost - Half Scholarship

$100.00

Full Scholarship

Whole Cost - Full Scholarship

$ Free

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Winter Retreat!

LEADER INFORMATION

MEDICAL INFORMATION

PAYMENT OPTIONS